1.2.40.0.34.6.0.11.2.168/static-2026-07-17T092528: Unterschied zwischen den Versionen

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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;">1.2.40.0.34.6.0.11.2.168</td><th style="width: 20em; text-align: left;">Gültigkeit ab</th><td style="text-align: left;">2026‑07‑17 09:25:28</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] Entwurf</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;">1.0.0</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">ClinicalInformationSection</td><th style="width: 20em; text-align: left;">Bezeichnung</th><td style="text-align: left;">Clinical Information Section</td></tr><tr style="vertical-align: top;"><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>
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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;">1.2.40.0.34.6.0.11.2.168</td><th style="width: 20em; text-align: left;">Gültigkeit ab</th><td style="text-align: left;">2026‑07‑17 09:25:28</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] Entwurf</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;">1.0.0</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">ClinicalInformationSection</td><th style="width: 20em; text-align: left;">Bezeichnung</th><td style="text-align: left;">Clinical Information Section</td></tr><tr style="vertical-align: top;"><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>Die Sektion „Klinische Angaben“ enthält die vom anfordernden Arzt bereitgestellten Angaben. Dazu zählen klinische Anamnese, präoperative Diagnose, postoperative Diagnose, Grund für die pathologische Untersuchung, klinische Laborbefunde sowie Informationen zum eingesandten Untersuchungsmaterial (einschließlich Entnahmeverfahren, Entnahmestelle, durchführender Person, Probenart,
<span lang="EN-US" style="mso-no-proof:no">The Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, reason for anatomic pathology procedure, clinical laboratory data, specimen sent for investigation (including collection procedure, target site, performer, specimen type,
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klinischer Beschreibung der Probe(n) und – im Falle einer Krebserkrankung – der Tumorlokalisation).</div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Kontext</th><td style="text-align: left;" colspan="3">Elternknoten des Template-Element mit Id 1.2.40.0.34.6.0.11.2.168</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Label</th><td style="text-align: left;" colspan="3">patho_section_ClinicalInformationSection<br /></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA 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">Geschlossen (nur definierte Elemente sind erlaubt)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beziehung</th><td style="text-align: left;" colspan="3">Spezialisierung: Template 1.3.6.1.4.1.19376.1.8.1.2.1 <i>Clinical Information Section </i> (2014‑05‑13 14:38:08) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">psr-</div></span><br />Spezialisierung: Template 2.16.840.1.113883.10.12.201 <i>CDA Section </i> (2005‑09‑07) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">ad1bbr-</div></span></td></tr><tr 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">generated example</span></td></tr><tr><td><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">section</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">DOCSECT</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.8.1.2.1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">22636-5</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">Pathology report relevant history</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">CLINICAL INFORMATION SECTION</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;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">text</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">languageCode</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">entry</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">ANY</span><span class="ppsign">"</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span> <span class="ppattribute">contextConductionInd</span><span class="ppsign">="</span><span class="ppcontent">true</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entry</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">component</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.1 'IHE Reason for Referral Section' (2016-09-26T07:58:18) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">component</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">component</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.4 'History of Present Illness Section'  (2013-01-31T00:00:00)<br /> --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">component</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">component</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.6 'IHE Active Problems Section' (2015-10-05T16:02:07) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">component</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></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>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">path...tion</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;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@moodCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><span style="color: grey;">[[File:EN-US.png]]  
specimen(s) clinical description, and tumor site in case of a cancer). </span>
 
</div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Kontext</th><td style="text-align: left;" colspan="3">Elternknoten des Template-Element mit Id 1.2.40.0.34.6.0.11.2.168</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Label</th><td style="text-align: left;" colspan="3">patho_section_ClinicalInformationSection<br /></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA 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">Geschlossen (nur definierte Elemente sind erlaubt)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beziehung</th><td style="text-align: left;" colspan="3">Spezialisierung: Template 1.3.6.1.4.1.19376.1.8.1.2.1 <i>Clinical Information Section </i> (2014‑05‑13 14:38:08) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">psr-</div></span><br />Spezialisierung: Template 2.16.840.1.113883.10.12.201 <i>CDA Section </i> (2005‑09‑07) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">ad1bbr-</div></span></td></tr><tr 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">generated example</span></td></tr><tr><td><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">section</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">DOCSECT</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.8.1.2.1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">22636-5</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">Pathology report relevant history</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">CLINICAL INFORMATION SECTION</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;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">text</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">languageCode</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">entry</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">ANY</span><span class="ppsign">"</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span> <span class="ppattribute">contextConductionInd</span><span class="ppsign">="</span><span class="ppcontent">true</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entry</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">component</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.1 'IHE Reason for Referral Section' (2016-09-26T07:58:18) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">component</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">component</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.4 'History of Present Illness Section'  (2013-01-31T00:00:00)<br /> --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">component</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">component</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.6 'IHE Active Problems Section' (2015-10-05T16:02:07) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">component</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></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>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">path...tion</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;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@moodCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><span style="color: grey;">[[File:EN-US.png]]  
 
 
<p style="margin: 0px; line-height: normal; -webkit-text-stroke-color: rgb(0, 0, 0);">
 
<p style="margin: 0px; line-height: normal; -webkit-text-stroke-color: rgb(0, 0, 0);">
 
<span style="-webkit-font-kerning: none;">This section SHALL contain a code element populated with these attributes:</span>
 
<span style="-webkit-font-kerning: none;">This section SHALL contain a code element populated with these attributes:</span>
Zeile 25: Zeile 23:
 
<span lang="EN-US">This section SHOULD contain <i>author</i> elements in case the authors of this section differ from those declared at a higher level in the document.</span>
 
<span lang="EN-US">This section SHOULD contain <i>author</i> elements in case the authors of this section differ from those declared at a higher level in the document.</span>
 
</p>  
 
</p>  
</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: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="">path...tion</span></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@root<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.40.0.34.6.0.11.2.168</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="">path...tion</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;">@displayName<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>st</td><td><span><strong>0 … 1</strong></span></td><td> </td><td style="vertical-align: top;" colspan="2"></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;">@codeSystemName<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>st</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" 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;">@code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td rowspan="2" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">22636-5</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; 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>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">path...tion</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 "Überweisungsgrund" sein</td></tr></table></td></tr><tr class="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Beispiel</td><td colspan="4" class="explabelgreen"><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">title</span><span class="ppsign">&gt;</span><span class="pptext">CLINICAL INFORMATION</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">&gt;</span></span></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: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></td><td style="background-color: #FFEEEE;"><span title="">path...tion</span></td></tr><tr class="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Beispiel</td><td colspan="4" class="explabelgreen"><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">&gt;</span><span class="pptext"> Tissue submitted: left breast biopsy and apical axillary tissue </span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span></span></td></tr></table></td></tr></table>
+
</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: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="">path...tion</span></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@root<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.40.0.34.6.0.11.2.168</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="">path...tion</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;">@displayName<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>st</td><td><span><strong>0 … 1</strong></span></td><td> </td><td style="vertical-align: top;" colspan="2"></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;">@codeSystemName<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>st</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" 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;">@code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td rowspan="2" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">22636-5</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; 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>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">path...tion</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 "Überweisungsgrund" 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></td><td style="background-color: #FFEEEE;"><span title="">path...tion</span></td></tr></table></td></tr></table>
<!--92d0b17934ee248623fde02efe88e84dafb2297a-->
+
<!--5478b87f34f42353679f77621c4a18665427c9ae-->

Version vom 6. September 2026, 23:25 Uhr

Id1.2.40.0.34.6.0.11.2.168Gültigkeit ab2026‑07‑17 09:25:28
StatusKyellow.png EntwurfVersions-Label1.0.0
NameClinicalInformationSectionBezeichnungClinical Information Section
Beschreibung
Die Sektion „Klinische Angaben“ enthält die vom anfordernden Arzt bereitgestellten Angaben. Dazu zählen klinische Anamnese, präoperative Diagnose, postoperative Diagnose, Grund für die pathologische Untersuchung, klinische Laborbefunde sowie Informationen zum eingesandten Untersuchungsmaterial (einschließlich Entnahmeverfahren, Entnahmestelle, durchführender Person, Probenart, klinischer Beschreibung der Probe(n) und – im Falle einer Krebserkrankung – der Tumorlokalisation).
KontextElternknoten des Template-Element mit Id 1.2.40.0.34.6.0.11.2.168
Labelpatho_section_ClinicalInformationSection
KlassifikationCDA Section level template
Offen/GeschlossenGeschlossen (nur definierte Elemente sind erlaubt)
BeziehungSpezialisierung: Template 1.3.6.1.4.1.19376.1.8.1.2.1 Clinical Information Section (2014‑05‑13 14:38:08)
ref
psr-

Spezialisierung: Template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
Beispiel
generated example
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.2.1"/>  <code code="22636-5" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report relevant history"/>  <title>CLINICAL INFORMATION SECTION</title>  <text/>  <languageCode/>  <entry xsi:type="ANY" typeCode="COMP" contextConductionInd="true">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) -->
  </entry>
  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->
  <component>
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.1 'IHE Reason for Referral Section' (2016-09-26T07:58:18) -->
  </component>
  <component>
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.4 'History of Present Illness Section' (2013-01-31T00:00:00)
-->
  </component>
  <component>
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.6 'IHE Active Problems Section' (2015-10-05T16:02:07) -->
  </component>
</section>
ItemDTKardKonfBeschreibungLabel
hl7:section
0 … 1Rpath...tion
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.png@moodCode
cs0 … 1FEVN
 ConstraintEN-US.png

This section SHALL contain a code element populated with these attributes:

@code="22636-5" 

@codeSystem="'2.16.840.1.113883.6.1" 

@displayName=" Pathology report relevant history”  

This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader.

The section SHOULD contain as many Problem Organizer entry elements as there are problems (or groups thereof) to be described. These entries provide the machine-readable data corresponding to the narrative block.

This section MAY contain a number of elements component/section introducing sub-sections, each of these sub-sections providing a particular type of clinical information.

This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.

Treetree.pnghl7:templateId
II1 … 1Rpath...tion
Treeblank.pngTreetree.png@root
uid1 … 1F1.2.40.0.34.6.0.11.2.168
Treetree.pnghl7:code
CE1 … 1Mpath...tion
Treeblank.pngTreetree.png@displayName
st0 … 1 
Treeblank.pngTreetree.png@codeSystemName
st0 … 1FLOINC
Treeblank.pngTreetree.png@code
CONF1 … 1F22636-5
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:title
ST1 … 1Rpath...tion
 CONF
Elementinhalt MUSS "Überweisungsgrund" sein
Treetree.pnghl7:text
SD.TEXT1 … 1Mpath...tion