1.2.40.0.34.11.5.2.9/static-2012-01-12T000000: Unterschied zwischen den Versionen

[unmarkierte Version]

Version vom 25. März 2021, 22:08 Uhr

Id

1.2.40.0.34.11.5.2.9

ref

elgabbr-

Gültigkeit

2012‑01‑12

Status

Aktiv

Versions-Label

Name

Befund

Bezeichnung

Befund

Kontext

Elternknoten des Template-Element mit Id 1.2.40.0.34.11.5.2.9

Klassifikation

CDA Section level template

Offen/Geschlossen

Offen (auch andere als die definierten Elemente sind erlaubt)

Benutzt

Benutzt 3 Templates

Benutzt	als	Name	Version
1.2.40.0.34.11.5.3.2	Containment	Kodierung des Befundtextes	DYNAMIC
1.2.40.0.34.11.5.3.1	Containment	BI-RADS® Klassifikation	DYNAMIC
1.2.40.0.34.11.1.3.1	Containment	Eingebettetes Objekt Entry	DYNAMIC

Beziehung

Version: Template 1.2.40.0.34.11.5.2.9 Befund (2012‑01‑12)

ref

elgabbr-

Beispiel

Strukturbeispiel Allgemein

<section>
  <templateId root="1.2.40.0.34.11.5.2.9"/>  
  <code code="18782-3" displayName="Study observation" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  
  <title>Befund</title>  
  <text> ... Lesbarer Textbereich ... </text></section>

Beispiel

Strukturbeispiel Mammographie mit BI-RADS® Klassifikation

<hl7:ClinicalDocument>
  <hl7:section>
    <hl7:templateId root="1.2.40.0.34.11.5.2.9"/>    
    <hl7:code code="18782-3" displayName="Study observation" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>    
    <hl7:title>Befund</hl7:title>    
    <hl7:text>
      <hl7:paragraph>
        <hl7:content ID="finding-1"> Parenchymasymmetrie. Verkalkte Ölcyste li. Sonst unauffälliger Befund bei Zustand nach Reduktionsplastik bds., derzeit kein Malignomhinweis. </hl7:content>      </hl7:paragraph>      <hl7:table>
        <hl7:thead>
          <hl7:tr>
            <hl7:th>Klassifikation</hl7:th>            <hl7:th>Wert</hl7:th>          </hl7:tr>        </hl7:thead>        <hl7:tbody>
          <hl7:tr>
            <hl7:td>BI-RADS</hl7:td>            <hl7:td ID="birads">4A</hl7:td>          </hl7:tr>          <hl7:tr>
            <hl7:td>ACR</hl7:td>            <hl7:td ID="acr">2</hl7:td>          </hl7:tr>        </hl7:tbody>      </hl7:table>    </hl7:text>    
    
    <hl7:entry>
      <hl7:observation classCode="OBS" moodCode="EVN">
        
        <hl7:templateId root="1.2.40.0.34.11.5.3.2"/>        <hl7:templateId root="2.16.840.1.113883.10.20.6.2.12"/>        <hl7:code code="121071" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Finding"/>        <hl7:value xsi:type="ED">
          <hl7:reference value="#finding1"/>        </hl7:value>      </hl7:observation>    </hl7:entry>    
    <hl7:entry>
      <hl7:observation classCode="OBS" moodCode="EVN">
        
        <hl7:templateId root="1.2.40.0.34.11.5.3.1"/>        <hl7:code code="36625-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Breast Mammogram"/>        <hl7:text>
          <hl7:reference value="#birads"/>        </hl7:text>        <hl7:statusCode code="completed"/>        <hl7:effectiveTime value="20110830103000+02"/>        <hl7:value xsi:type="CD" code="MA.II.A.5.4A" codeSystem="1.2.40.0.34.5.49" codeSystemName="ELGA_MammogramAssessment"/>      </hl7:observation>    </hl7:entry>  </hl7:section></hl7:ClinicalDocument>

Item

DT

Kard

Konf

Beschreibung

Label

hl7:section

(Befund)

@classCode

cs

0 … 1

F

DOCSECT

hl7:templateId

II

1 … 1

R

(Befund)

@root

uid

1 … 1

F

1.2.40.0.34.11.5.2.9

hl7:code

CE

1 … 1

M

(Befund)

@code

CONF

1 … 1

F

18782-3

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

@codeSystemName

1 … 1

F

LOINC

@displayName

1 … 1

F

Study observation

hl7:title

ST

1 … 1

M

(Befund)

CONF

Elementinhalt muss "Befund" sein

hl7:text

SD.TEXT

1 … 1

M

Befundtext sollte in Abschnitte (<paragraph>) gegliedert sein. Vorgegebene Struktur für Mammographie: Klassifikationen nach BI-RADS® oder nach ACR Index MÜSSEN im Textteil als Tabelle enthalten sein.

Empfohlen wird die Angabe der BI-RADS® Klassen in arabischen Ziffern.

(Befund)

hl7:entry

Beinhaltet 1.2.40.0.34.11.5.3.2 Kodierung des Befundtextes (DYNAMIC)

(Befund)

hl7:entry

Beinhaltet 1.2.40.0.34.11.5.3.1 BI-RADS® Klassifikation (DYNAMIC)

(Befund)

hl7:entry

0 … *

R

Beinhaltet 1.2.40.0.34.11.1.3.1 Eingebettetes Objekt Entry (DYNAMIC)

(Befund)

Version vom 5. Januar 2021, 22:21 Uhr (Quelltext anzeigen) ADbot (Diskussion \| Beiträge) (Automatic ADBot page (4bb514f5a89f30cda710acf2d96a99f5ca1366fd)) ← Zum vorherigen Versionsunterschied		Version vom 25. März 2021, 22:08 Uhr (Quelltext anzeigen) ADbot (Diskussion \| Beiträge) (Automatic ADBot page (4bb514f5a89f30cda710acf2d96a99f5ca1366fd)) Zum nächsten Versionsunterschied →
Zeile 1:		Zeile 1:
−	<table xmlns="http://www.w3.org/1999/xhtml" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.2.40.0.34.11.5.2.9 <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">elgabbr-</div></span></td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2012‑01‑12</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kgreen.png\|14px]] Aktiv</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;"></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">Befund</td><th style="width: 20em; text-align: left;">Bezeichnung</th><td style="text-align: left;">Befund</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 1.2.40.0.34.11.5.2.9</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;">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 3 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;">1.2.40.0.34.11.5.3.2</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png\|14px]] Kodierung des Befundtextes</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.11.5.3.1</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png\|14px]] BI-RADS® Klassifikation</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.11.1.3.1</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png\|14px]] Eingebettetes Objekt Entry</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">Version: Template 1.2.40.0.34.11.5.2.9 <i>Befund </i> (2012‑01‑12) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">elgabbr-</div></span></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">Strukturbeispiel Allgemein</span></td></tr><tr><td><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">section</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.11.5.2.9</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Code der Sektion --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">18782-3</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Study observation</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="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Titel der Sektion --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">title</span><span class="ppsign">></span><span class="pptext">Befund</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Textbereich der Sektion --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">text</span><span class="ppsign">></span><span class="pptext"> ... Lesbarer Textbereich ... </span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">></span></span></span></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">Strukturbeispiel Mammographie mit BI-RADS® Klassifikation</span></td></tr><tr><td><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">ClinicalDocument</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">section</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.11.5.2.9</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Code der Sektion --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">18782-3</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Study observation</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="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Titel der Sektion --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">title</span><span class="ppsign">></span><span class="pptext">Befund</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">title</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Textbereich der Sektion --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">paragraph</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">content</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">finding-1</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext"> Parenchymasymmetrie. Verkalkte Ölcyste li. Sonst unauffälliger Befund bei Zustand nach Reduktionsplastik bds., derzeit kein Malignomhinweis. </span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">content</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">paragraph</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">table</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">thead</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">th</span><span class="ppsign">></span><span class="pptext">Klassifikation</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">th</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">th</span><span class="ppsign">></span><span class="pptext">Wert</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">th</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">thead</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">tbody</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">></span><span class="pptext">BI-RADS</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">birads</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">4A</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">></span><span class="pptext">ACR</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">acr</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">2</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">tbody</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">table</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Maschinenlesbare Elemente der Sektion --><br /></span></span><span style="display: block;"> <span style="color:green"><!-- Entry fuer die Codierung des Befundtextes --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">entry</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">OBS</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">></span><br /><span style="display: block;"> <span style="color:green"><!-- Text Observation --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.11.5.3.2</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.10.20.6.2.12</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">121071</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.840.10008.2.16.4</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">DCM</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Finding</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">ED</span><span class="ppsign">"</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#finding1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">entry</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- entry fuer ELGA BI-RADS® Codierung --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">entry</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">OBS</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">></span><br /><span style="display: block;"> <span style="color:green"><!-- Mammography Observation --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.11.5.3.1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">36625-2</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">Breast Mammogram</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#birads</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</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">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">effectiveTime</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20110830103000+02</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">CD</span><span class="ppsign">"</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">MA.II.A.5.4A</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.5.49</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">ELGA_MammogramAssessment</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">entry</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">section</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">ClinicalDocument</span><span class="ppsign">></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:section<br xmlns="http://www.w3.org/1999/xhtml" /></span></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></td><td style="background-color: #FFEEEE;"><span title="">(Befund)</span></td></tr><tr><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>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">DOCSECT</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>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Befund)</span></td></tr><tr><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">1.2.40.0.34.11.5.2.9</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>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="">(Befund)</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="4" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">18782-3</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;">@codeSystem<br xmlns="http://www.w3.org/1999/xhtml" /></span></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 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;">@codeSystemName<br xmlns="http://www.w3.org/1999/xhtml" /></span></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 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;">@displayName<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">Study observation</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:title<br xmlns="http://www.w3.org/1999/xhtml" /></span></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="">(Befund)</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 width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>Elementinhalt muss "Befund" sein</td></tr></table></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>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>Befundtext sollte in Abschnitte (<paragraph>) gegliedert sein. Vorgegebene Struktur für Mammographie: Klassifikationen nach BI-RADS® oder nach ACR Index MÜSSEN im Textteil als Tabelle enthalten sein.</div><div>Empfohlen wird die Angabe der BI-RADS® Klassen in arabischen Ziffern.</div></td><td style="background-color: #FFEEEE;"><span title="">(Befund)</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:entry<br xmlns="http://www.w3.org/1999/xhtml" /></span></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>Beinhaltet 1.2.40.0.34.11.5.3.2 <i>Kodierung des Befundtextes</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Befund)</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:entry<br xmlns="http://www.w3.org/1999/xhtml" /></span></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>Beinhaltet 1.2.40.0.34.11.5.3.1 <i>BI-RADS® Klassifikation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Befund)</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:entry<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>Beinhaltet 1.2.40.0.34.11.1.3.1 <i>Eingebettetes Objekt Entry</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Befund)</span></td></tr></table></td></tr></table>	+	<table xmlns="http://www.w3.org/1999/xhtml" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.2.40.0.34.11.5.2.9 <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">elgabbr-</div></span></td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2012‑01‑12</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kgreen.png\|14px]] Aktiv</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;"></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">Befund</td><th style="width: 20em; text-align: left;">Bezeichnung</th><td style="text-align: left;">Befund</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 1.2.40.0.34.11.5.2.9</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;">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 3 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;">1.2.40.0.34.11.5.3.2</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png\|14px]] Kodierung des Befundtextes</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.11.5.3.1</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png\|14px]] BI-RADS® Klassifikation</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.11.1.3.1</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png\|14px]] Eingebettetes Objekt Entry</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">Version: Template 1.2.40.0.34.11.5.2.9 <i>Befund </i> (2012‑01‑12) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">elgabbr-</div></span></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">Strukturbeispiel Allgemein</span></td></tr><tr><td><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">section</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.11.5.2.9</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Code der Sektion --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">18782-3</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Study observation</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="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Titel der Sektion --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">title</span><span class="ppsign">></span><span class="pptext">Befund</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Textbereich der Sektion --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">text</span><span class="ppsign">></span><span class="pptext"> ... Lesbarer Textbereich ... </span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">></span></span></span></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">Strukturbeispiel Mammographie mit BI-RADS® Klassifikation</span></td></tr><tr><td><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">ClinicalDocument</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">section</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.11.5.2.9</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Code der Sektion --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">18782-3</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Study observation</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="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Titel der Sektion --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">title</span><span class="ppsign">></span><span class="pptext">Befund</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">title</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Textbereich der Sektion --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">paragraph</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">content</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">finding-1</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext"> Parenchymasymmetrie. Verkalkte Ölcyste li. Sonst unauffälliger Befund bei Zustand nach Reduktionsplastik bds., derzeit kein Malignomhinweis. </span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">content</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">paragraph</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">table</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">thead</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">th</span><span class="ppsign">></span><span class="pptext">Klassifikation</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">th</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">th</span><span class="ppsign">></span><span class="pptext">Wert</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">th</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">thead</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">tbody</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">></span><span class="pptext">BI-RADS</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">birads</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">4A</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">></span><span class="pptext">ACR</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">acr</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">2</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">tbody</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">table</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Maschinenlesbare Elemente der Sektion --><br /></span></span><span style="display: block;"> <span style="color:green"><!-- Entry fuer die Codierung des Befundtextes --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">entry</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">OBS</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">></span><br /><span style="display: block;"> <span style="color:green"><!-- Text Observation --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.11.5.3.2</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.10.20.6.2.12</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">121071</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.840.10008.2.16.4</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">DCM</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Finding</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">ED</span><span class="ppsign">"</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#finding1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">entry</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- entry fuer ELGA BI-RADS® Codierung --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">entry</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">OBS</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">></span><br /><span style="display: block;"> <span style="color:green"><!-- Mammography Observation --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.11.5.3.1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">36625-2</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">Breast Mammogram</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#birads</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</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">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">effectiveTime</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20110830103000+02</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">CD</span><span class="ppsign">"</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">MA.II.A.5.4A</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.5.49</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">ELGA_MammogramAssessment</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">entry</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">section</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">ClinicalDocument</span><span class="ppsign">></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:section<br xmlns="http://www.w3.org/1999/xhtml" /></span></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></td><td style="background-color: #FFEEEE;"><span title="">(Befund)</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>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">DOCSECT</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>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Befund)</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">1.2.40.0.34.11.5.2.9</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>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="">(Befund)</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="4" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">18782-3</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;">@codeSystem<br xmlns="http://www.w3.org/1999/xhtml" /></span></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 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;">@codeSystemName<br xmlns="http://www.w3.org/1999/xhtml" /></span></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 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;">@displayName<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">Study observation</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:title<br xmlns="http://www.w3.org/1999/xhtml" /></span></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="">(Befund)</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 width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>Elementinhalt muss "Befund" sein</td></tr></table></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>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>Befundtext sollte in Abschnitte (<paragraph>) gegliedert sein. Vorgegebene Struktur für Mammographie: Klassifikationen nach BI-RADS® oder nach ACR Index MÜSSEN im Textteil als Tabelle enthalten sein.</div><div>Empfohlen wird die Angabe der BI-RADS® Klassen in arabischen Ziffern.</div></td><td style="background-color: #FFEEEE;"><span title="">(Befund)</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:entry<br xmlns="http://www.w3.org/1999/xhtml" /></span></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>Beinhaltet 1.2.40.0.34.11.5.3.2 <i>Kodierung des Befundtextes</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Befund)</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:entry<br xmlns="http://www.w3.org/1999/xhtml" /></span></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>Beinhaltet 1.2.40.0.34.11.5.3.1 <i>BI-RADS® Klassifikation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Befund)</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:entry<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>Beinhaltet 1.2.40.0.34.11.1.3.1 <i>Eingebettetes Objekt Entry</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Befund)</span></td></tr></table></td></tr></table>
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1.2.40.0.34.11.5.2.9/static-2012-01-12T000000: Unterschied zwischen den Versionen

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