1.2.40.0.34.6.0.11.2.10/static-2018-10-09T133507: Unterschied zwischen den Versionen

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     <br />Synonyme: Aktuelle Anamnese </div></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">Elternknoten des Template-Element mit Id 1.2.40.0.34.6.0.11.2.10</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Section 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;">Assoziiert mit</th><td style="text-align: left;" colspan="3"><table class="treetable" id="assocsTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Assoziiert mit 1 Konzept</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;">Id</th><th style="width: 60%; text-align: left;">Name</th><th style="width: 20%; text-align: left;">Datensatz</th></tr><tr><td style="text-align: left; vertical-align: top; width: 1%;">elgagab-data&#8203;element-169</td><td style="vertical-align: top;" title="Fachlicher Inhalt (Sektionen) / ">[[File:Kyellow.png|14px]] Anamnese </td><td style="text-align: left; vertical-align: top;">[[File:Kyellow.png|14px]] Datensatz  </td></tr></table></div></td></tr></table></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 13 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;">1.2.40.0.34.6.0.11.2.16</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Frühere Erkrankungen - unkodiert (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.3</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Frühere Erkrankungen - kodiert (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.49</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Schwangerschaften - unkodiert (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.11.13.2.9</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Schwangerschaften (0.1)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.50</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Medizinische Geräte und Implantate - unkodiert (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.60</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Medizinische Geräte und Implantate - kodiert (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.52</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Beeinträchtigungen - unkodiert (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.51</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Beeinträchtigungen - kodiert (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.53</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Impfungen - unkodiert (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.1</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Impfungen - kodiert (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.54</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Lebensstil - unkodiert (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.55</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Lebensstil - kodiert (2019)</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:Kyellow.png|14px]] Willenserklärungen und andere juridische Dokumente (2019)</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr class="explabel " style="vertical-align: top;"><td style="width: 20em; text-align: left;">Beispiel</td><td colspan="3" class="explabelgreen"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Strukturbeispiel</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">section</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">1.2.40.0.34.6.0.11.2.10</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="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">10164-2</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">History of present illness</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">title</span><span class="ppsign">&gt;</span><span class="pptext">Anamnese</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- Textbereich der Sektion --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">&gt;</span><span class="pptext"> ... Lesbarer Textbereich ... </span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- choice: Eine beliebige Zusammenstellung aus den unten definierten Auswahlmöglichkeiten --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">section</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">1.2.40.0.34.6.0.11.2.16</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- ...  --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">&gt;</span></span></tt></td></tr></table></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:section<br /></strong></tt></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></td><td style="background-color: #FFEEEE;"><span title="">(elg...ese)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="2">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">elgagab-data&#8203;element-169</td><td style="vertical-align: top;" title="Fachlicher Inhalt (Sektionen) / ">[[File:Kyellow.png|14px]] Anamnese </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] Datensatz  </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:Treetree.png|16px]]</td><td><tt><strong>hl7:templateId<br /></strong></tt></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="">(elg...ese)</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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@root<br /></strong></tt></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">1.2.40.0.34.6.0.11.2.10</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:code<br /></strong></tt></td></tr></table></td><td><strong>CE</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...ese)</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:Treetree.png|16px]]</td><td><tt><strong>@code<br /></strong></tt></td></tr></table></td><td rowspan="4" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">10164-2</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: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">2.16.840.1.113883.6.1 (LOINC)</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:Treetree.png|16px]]</td><td><tt><strong>@codeSystemName<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">LOINC</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:Treetree.png|16px]]</td><td><tt><strong>@displayName<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">History of present illness</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:title<br /></strong></tt></td></tr></table></td><td><strong>ST</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...ese)</span></td></tr><tr style="vertical-align: top; background-color: #FFEEEE;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4" style="background-color: white;"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>Elementinhalt muss "Anamnese" sein</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:Treetree.png|16px]]</td><td><tt><strong>hl7:text<br /></strong></tt></td></tr></table></td><td><strong>SD.TEXT</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>Freitext für aktuelle Anamnese.<br />
+
     <br />Synonyme: Aktuelle Anamnese </div></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">Elternknoten des Template-Element mit Id 1.2.40.0.34.6.0.11.2.10</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Section 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;">Assoziiert mit</th><td style="text-align: left;" colspan="3"><table class="treetable" id="assocsTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Assoziiert mit 1 Konzept</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;">Id</th><th style="width: 60%; text-align: left;">Name</th><th style="width: 20%; text-align: left;">Datensatz</th></tr><tr><td style="text-align: left; vertical-align: top; width: 1%;">elgagab-data&#8203;element-169</td><td style="vertical-align: top;" title="Fachlicher Inhalt (Sektionen) / ">[[File:Kyellow.png|14px]] Anamnese </td><td style="text-align: left; vertical-align: top;">[[File:Kyellow.png|14px]] Datensatz  </td></tr></table></div></td></tr></table></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 13 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;">1.2.40.0.34.6.0.11.2.16</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Frühere Erkrankungen - unkodiert (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.3</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Frühere Erkrankungen - kodiert (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.49</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Schwangerschaften - unkodiert (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.11.13.2.9</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Schwangerschaften (0.1)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.50</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Medizinische Geräte und Implantate - unkodiert (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.60</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Medizinische Geräte und Implantate - kodiert (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.52</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Beeinträchtigungen - unkodiert (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.51</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Beeinträchtigungen - kodiert (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.53</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Impfungen - unkodiert (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.1</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Impfungen - kodiert (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.54</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Lebensstil - unkodiert (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.55</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Lebensstil - kodiert (2019)</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:Kyellow.png|14px]] Willenserklärungen und andere juridische Dokumente (2019)</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr class="explabel " style="vertical-align: top;"><td style="width: 20em; text-align: left;">Beispiel</td><td colspan="3" class="explabelgreen"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Strukturbeispiel</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">section</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">1.2.40.0.34.6.0.11.2.10</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="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">10164-2</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">LOINC</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">History of present illness</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">title</span><span class="ppsign">&gt;</span><span class="pptext">Anamnese</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- Textbereich der Sektion --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">&gt;</span><span class="pptext"> ... Lesbarer Textbereich ... </span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- choice: Eine beliebige Zusammenstellung aus den unten definierten Auswahlmöglichkeiten --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">section</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">1.2.40.0.34.6.0.11.2.16</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- ...  --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">&gt;</span></span></tt></td></tr></table></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:section<br /></strong></tt></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></td><td style="background-color: #FFEEEE;"><span title="">(elg...ese)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="2">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">elgagab-data&#8203;element-169</td><td style="vertical-align: top;" title="Fachlicher Inhalt (Sektionen) / ">[[File:Kyellow.png|14px]] Anamnese </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] Datensatz  </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:Treetree.png|16px]]</td><td><tt><strong>hl7:templateId<br /></strong></tt></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="">(elg...ese)</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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@root<br /></strong></tt></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">1.2.40.0.34.6.0.11.2.10</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:code<br /></strong></tt></td></tr></table></td><td><strong>CE</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...ese)</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:Treetree.png|16px]]</td><td><tt><strong>@code<br /></strong></tt></td></tr></table></td><td rowspan="4" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">10164-2</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: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">2.16.840.1.113883.6.1 (LOINC)</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:Treetree.png|16px]]</td><td><tt><strong>@codeSystemName<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">LOINC</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:Treetree.png|16px]]</td><td><tt><strong>@displayName<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">History of present illness</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:title<br /></strong></tt></td></tr></table></td><td><strong>ST</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...ese)</span></td></tr><tr style="vertical-align: top; background-color: #FFEEEE;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4" style="background-color: white;"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>Elementinhalt muss "Anamnese" sein</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:Treetree.png|16px]]</td><td><tt><strong>hl7:text<br /></strong></tt></td></tr></table></td><td><strong>SD.TEXT</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>Freitext für aktuelle Anamnese.<br />
 
     <ul>
 
     <ul>
 
         <li>Gutes Beispiel: „Thoraxschmerzen bei leichter Belastung seit zwei Wochen. Vorherige Herzprobleme bekannt.“</li>
 
         <li>Gutes Beispiel: „Thoraxschmerzen bei leichter Belastung seit zwei Wochen. Vorherige Herzprobleme bekannt.“</li>

Version vom 29. November 2019, 05:32 Uhr

Id1.2.40.0.34.6.0.11.2.10
ref
elgagab-
Gültigkeit2018‑10‑09 13:35:07
StatusKyellow.png EntwurfVersions-Label2019
Nameelgagab_section_anamneseAnzeigenameAnamnese
Beschreibung
Die Anamnese enthält die professionelle Erfragung von potenziell medizinisch relevanten Informationen durch Fachpersonal (z.B. einen Arzt) basierend auf den Aussagen des Patienten (Eigenanamnese) oder einer dritten Person (Fremdanamnese) zum aktuellen Konsultationsanlass. 
Die Anamnese kann sich in mehrere Abschnitte gliedern, z.B.
  • biografische Anamnese, allgemeine Anamnese,
  • vegetative Anamnese,
  • Ernährungsanamnese,
  • Suchtanamnese,
  • psychosoziale Anamnese,
  • Sexualanamnese,
  • Familienanamnese
  • Sozialanamnese
  • Fachspezifische Anamnese
Wenn eine höhere Strukturierung notwendig ist, können die angegebenen Subsektionen eingefügt werden.
   Fachspezifische Erweiterung: Fachspezifisch notwendige strukturierte oder codierte Daten müssen in einer separat definierten offiziellen Untersektion eingefügt werden.

   
Mögliche Untersektionen:
  • Frühere Erkrankungen (kodiert oder narrativ)
  • Schwangerschaften 
  • Medizinische Geräte und Implantate
  • Beeinträchtigungen 
  • Impfungen 
  • Lebensstil 
  • Willenserklärungen
  • Fachspezifische Anamnese

Synonyme: Aktuelle Anamnese
KontextElternknoten des Template-Element mit Id 1.2.40.0.34.6.0.11.2.10
KlassifikationCDA Section level template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Assoziiert mit
Assoziiert mit 1 Konzept
IdNameDatensatz
elgagab-data​element-169Kyellow.png Anamnese Kyellow.png Datensatz
Benutzt
Benutzt 13 Templates
Benutzt als NameVersion
1.2.40.0.34.6.0.11.2.16ContainmentKyellow.png Frühere Erkrankungen - unkodiert (2019)DYNAMIC
1.2.40.0.34.6.0.11.2.3ContainmentKyellow.png Frühere Erkrankungen - kodiert (2019)DYNAMIC
1.2.40.0.34.6.0.11.2.49ContainmentKyellow.png Schwangerschaften - unkodiert (2019)DYNAMIC
1.2.40.0.34.11.13.2.9ContainmentKyellow.png Schwangerschaften (0.1)DYNAMIC
1.2.40.0.34.6.0.11.2.50ContainmentKyellow.png Medizinische Geräte und Implantate - unkodiert (2019)DYNAMIC
1.2.40.0.34.6.0.11.2.60ContainmentKyellow.png Medizinische Geräte und Implantate - kodiert (2019)DYNAMIC
1.2.40.0.34.6.0.11.2.52ContainmentKyellow.png Beeinträchtigungen - unkodiert (2019)DYNAMIC
1.2.40.0.34.6.0.11.2.51ContainmentKyellow.png Beeinträchtigungen - kodiert (2019)DYNAMIC
1.2.40.0.34.6.0.11.2.53ContainmentKyellow.png Impfungen - unkodiert (2019)DYNAMIC
1.2.40.0.34.6.0.11.2.1ContainmentKyellow.png Impfungen - kodiert (2019)DYNAMIC
1.2.40.0.34.6.0.11.2.54ContainmentKyellow.png Lebensstil - unkodiert (2019)DYNAMIC
1.2.40.0.34.6.0.11.2.55ContainmentKyellow.png Lebensstil - kodiert (2019)DYNAMIC
1.2.40.0.34.6.0.11.2.61ContainmentKyellow.png Willenserklärungen und andere juridische Dokumente (2019)DYNAMIC
Beispiel
Strukturbeispiel
<section>
  <templateId root="1.2.40.0.34.6.0.11.2.10"/>  <code code="10164-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of present illness"/>  <title>Anamnese</title>  <!-- Textbereich der Sektion -->
  <text> ... Lesbarer Textbereich ... </text>  <!-- choice: Eine beliebige Zusammenstellung aus den unten definierten Auswahlmöglichkeiten -->
  <section>
    <templateId root="1.2.40.0.34.6.0.11.2.16"/>    <!-- ... -->
  </section></section>
ItemDTKardKonfBeschreibungLabel
hl7:section
0 … 1(elg...ese)
 
Target.png
elgagab-data​element-169Kyellow.png Anamnese Kyellow.png Datensatz
Treetree.pnghl7:templateId
II1 … 1M(elg...ese)
Treeblank.pngTreetree.png@root
uid1 … 1F1.2.40.0.34.6.0.11.2.10
Treetree.pnghl7:code
CE1 … 1M(elg...ese)
Treeblank.pngTreetree.png@code
CONF1 … 1F10164-2
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1FHistory of present illness
Treetree.pnghl7:title
ST1 … 1M(elg...ese)
 CONF
Elementinhalt muss "Anamnese" sein
Treetree.pnghl7:text
SD.TEXT1 … 1M
Freitext für aktuelle Anamnese.
  • Gutes Beispiel: „Thoraxschmerzen bei leichter Belastung seit zwei Wochen. Vorherige Herzprobleme bekannt.“
  • Schlechtes Beispiel: Kopie sämtlicher Vordiagnosen
(elg...ese)
Auswahl0 … 1Elemente in der Auswahl:
  • hl7:component welches enthält Template 1.2.40.0.34.6.0.11.2.16 Frühere Erkrankungen - unkodiert (DYNAMIC)
  • hl7:component welches enthält Template 1.2.40.0.34.6.0.11.2.3 Frühere Erkrankungen - kodiert (DYNAMIC)
Treeblank.pngTreetree.pnghl7:component
0 … 1Beinhaltet 1.2.40.0.34.6.0.11.2.16 Frühere Erkrankungen - unkodiert (DYNAMIC)(elg...ese)
Treeblank.pngTreeblank.png wo [hl7:section]
Treeblank.pngTreetree.pnghl7:component
0 … 1Beinhaltet 1.2.40.0.34.6.0.11.2.3 Frühere Erkrankungen - kodiert (DYNAMIC)(elg...ese)
Treeblank.pngTreeblank.png wo [hl7:section]
Auswahl0 … 1Elemente in der Auswahl:
  • hl7:component welches enthält Template 1.2.40.0.34.6.0.11.2.49 Schwangerschaften - unkodiert (DYNAMIC)
  • hl7:component welches enthält Template 1.2.40.0.34.11.13.2.9 Schwangerschaften (DYNAMIC)
Treeblank.pngTreetree.pnghl7:component
0 … 1Beinhaltet 1.2.40.0.34.6.0.11.2.49 Schwangerschaften - unkodiert (DYNAMIC)(elg...ese)
Treeblank.pngTreeblank.png wo [hl7:section [hl7:code [(@code = '10162-6' and @codeSystem = '2.16.840.1.113883.6.1')]]]
Treeblank.pngTreetree.pnghl7:component
0 … 1Beinhaltet 1.2.40.0.34.11.13.2.9 Schwangerschaften (DYNAMIC)(elg...ese)
Treeblank.pngTreeblank.png wo [hl7:section [hl7:code [(@code = '10162-6' and @codeSystem = '2.16.840.1.113883.6.1')]]]
Auswahl0 … 1Elemente in der Auswahl:
  • hl7:component welches enthält Template 1.2.40.0.34.6.0.11.2.50 Medizinische Geräte und Implantate - unkodiert (DYNAMIC)
  • hl7:component welches enthält Template 1.2.40.0.34.6.0.11.2.60 Medizinische Geräte und Implantate - kodiert (DYNAMIC)
Treeblank.pngTreetree.pnghl7:component
0 … 1Beinhaltet 1.2.40.0.34.6.0.11.2.50 Medizinische Geräte und Implantate - unkodiert (DYNAMIC)(elg...ese)
Treeblank.pngTreeblank.png wo [hl7:section [hl7:code [(@code = '46264-8' and @codeSystem = '2.16.840.1.113883.6.1')]]]
Treeblank.pngTreetree.pnghl7:component
0 … 1Beinhaltet 1.2.40.0.34.6.0.11.2.60 Medizinische Geräte und Implantate - kodiert (DYNAMIC)(elg...ese)
Treeblank.pngTreeblank.png wo [hl7:section [hl7:code [(@code = '46264-8' and @codeSystem = '2.16.840.1.113883.6.1')]]]
Auswahl0 … 1Elemente in der Auswahl:
  • hl7:component welches enthält Template 1.2.40.0.34.6.0.11.2.52 Beeinträchtigungen - unkodiert (DYNAMIC)
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