1.2.40.0.34.6.0.11.2.111/static-2021-01-18T143448: Unterschied zwischen den Versionen

[unmarkierte Version]

Version vom 14. Dezember 2021, 00:00 Uhr

Id

1.2.40.0.34.6.0.11.2.111

Gültigkeit

2021‑01‑18 14:34:48

Status

Aktiv

Versions-Label

1.0.0+20211213

Name

atlab_section_AnamneseLaborUndMikrobiologieUncodiert

Bezeichnung

Anamnese - Labor und Mikrobiologie - uncodiert

Beschreibung

Diese Section dient zur Dokumentation der Anamnese. In erster Linie soll oberflächlich erfasst werden, ob für den Patienten gewisse Aspekte aus seiner Krankengeschichte zutreffen oder nicht.

Darstellung der Ergebnisse

"section/text" enthält den narrativen Text, der der CDA Level 2 Darstellung der medizinischen Inhalte entspricht. Die Darstellung der Anamnese in "section/text" erfolgt idealerweise tabellarisch, wobei die Tabelle wie folgt aufgebaut sein sollte.

Spaltenname	Beschreibung
Aspekt	Angabe des Aspekts der Krankengeschichte, der erhoben worden ist.
Ergebnis	Binäres Ergebnis der Bewertung des Aspekts in der Form "trifft zu" oder "trifft nicht zu".

Kontext

Elternknoten des Template-Element mit Id 1.2.40.0.34.6.0.11.2.111

Klassifikation

CDA Section level template

Offen/Geschlossen

Geschlossen (nur definierte Elemente sind erlaubt)

Benutzt

Benutzt 1 Template

Benutzt	als	Name	Version
1.2.40.0.34.6.0.11.2.8	Containment	Übersetzung (1.0.1+20210628)	DYNAMIC

Beziehung

Adaptation: Template 1.2.40.0.34.6.0.11.2.98 Fachspezifische Anamnese (2021‑02‑19 09:05:57)

ref

elgagab-

Beispiel

<section>
  <templateId root="1.2.40.0.34.6.0.11.2.111"/>  <code code="10164-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Present illness Narrative"/>  <title>Anamnese</title>  
  <text>
    <table>
      <thead>
        <tr>
          <th>Aspekt</th>          <th>Ergebnis</th>        </tr>      </thead>      <tbody>
        <tr ID="OBS-1-1">
          <td>Vorgeschichte einer chronischen Harnwegsinfektion</td>          <td>trifft zu</td>        </tr>        <tr ID="OBS-1-2">
          <td>Vorgeschichte einer Knochenmarktransplantation</td>          <td>trifft nicht zu</td>        </tr>        
      </tbody>    </table>  </text></section>

Item

DT

Kard

Konf

Beschreibung

Label

hl7:section

(atl...ert)

@classCode

cs

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EVN

hl7:templateId

II

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Anamnese - Labor und Mikrobiologie - uncodiert

(atl...ert)

@root

uid

1 … 1

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1.2.40.0.34.6.0.11.2.111

hl7:id

II

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(atl...ert)

wo [not(@nullFlavor)]

hl7:code

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History of Present illness Narrative

hl7:title

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Elementinhalt muss "Anamnese" sein

hl7:text

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Narrativer Text

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hl7:component

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Optionale Subsections zur Angabe von Übersetzungen des "text"-Elementes

Beinhaltet 1.2.40.0.34.6.0.11.2.8 Übersetzung (DYNAMIC)

(atl...ert)

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cs

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F

COMP

@contextConductionInd

cs

0 … 1

F

true

@@ Zeile 1: / Zeile 1: @@
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+<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;">1.2.40.0.34.6.0.11.2.111</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2021‑01‑18 14:34:48</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;">1.0.0+20211213</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">atlab_section_AnamneseLaborUndMikrobiologieUncodiert</td><th style="width: 20em; text-align: left;">Bezeichnung</th><td style="text-align: left;">Anamnese - Labor und Mikrobiologie - uncodiert</td></tr><td style="text-align: left;" colspan="4"><table id="templateDescTable" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Beschreibung</td></tr><tr><td><div>Diese Section dient zur Dokumentation der Anamnese. In erster Linie soll oberflächlich erfasst werden, ob für den Patienten gewisse Aspekte aus seiner Krankengeschichte zutreffen oder nicht. <br />
 <br />
 <b>Darstellung der Ergebnisse</b>
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-<!--3aec0c760cdc1eb5f65d3f4b39ee03b27d4bd3ea-->
+<!--bcb9a300c85ff122918f8e8c7db449c3d2c72c2d-->

1.2.40.0.34.6.0.11.2.111/static-2021-01-18T143448: Unterschied zwischen den Versionen

Version vom 14. Dezember 2021, 00:00 Uhr

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