elga-cdaps-2.06.2:Einleitung: Unterschied zwischen den Versionen
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== Ausgangssituation == | == Ausgangssituation == | ||
Hier kommt noch Text her .... | Hier kommt noch Text her .... | ||
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| + | Definition des Patient Summary Dokuments | ||
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| + | '''60591-5 Patient summary Document''' | ||
| + | This document is a concise clinical document that provides an electronic, pre-defined patient health data set applicable both for unexpected, as well as expected (planned), health care contact. This document may be either the product of a medical act or an automatic excerpt from national/regional EHRs. | ||
| + | A Patient Summary gives a healthcare provider the essential information needed for health care coordination and, in cases of an unexpected need or when the patient consults a provider other than his regular contact person (e.g. the general practitioner he/she is registered with), this document enables continuity of care. | ||
| + | Because it is meant to be a summary, this document might not include a detailed medical history, details on clinical conditions or a full list of all prescriptions and dispensed medicines. | ||
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| + | '''60592-3 Patient summary.unexpected contact Document''' | ||
| + | This document is a concise clinical document that provides an electronic, pre-defined patient health data set applicable for unexpected health care contact (e.g. emergencies, GP substitutions). | ||
| + | This document gives a synthetic (and generic) picture of a patient by providing only his/her "essential information", e.g. allergies, current medications, active or past problems. Because it is meant to be a summary, this document might not include a detailed medical history, details on clinical conditions or a full list of all prescriptions and dispensed medicines. | ||
== Zweck == | == Zweck == | ||
Version vom 10. Mai 2017, 17:41 Uhr
Inhaltsverzeichnis
1 Einleitung
1.1 Ausgangssituation
Hier kommt noch Text her ....
Definition des Patient Summary Dokuments
60591-5 Patient summary Document This document is a concise clinical document that provides an electronic, pre-defined patient health data set applicable both for unexpected, as well as expected (planned), health care contact. This document may be either the product of a medical act or an automatic excerpt from national/regional EHRs. A Patient Summary gives a healthcare provider the essential information needed for health care coordination and, in cases of an unexpected need or when the patient consults a provider other than his regular contact person (e.g. the general practitioner he/she is registered with), this document enables continuity of care. Because it is meant to be a summary, this document might not include a detailed medical history, details on clinical conditions or a full list of all prescriptions and dispensed medicines.
60592-3 Patient summary.unexpected contact Document This document is a concise clinical document that provides an electronic, pre-defined patient health data set applicable for unexpected health care contact (e.g. emergencies, GP substitutions). This document gives a synthetic (and generic) picture of a patient by providing only his/her "essential information", e.g. allergies, current medications, active or past problems. Because it is meant to be a summary, this document might not include a detailed medical history, details on clinical conditions or a full list of all prescriptions and dispensed medicines.
1.2 Zweck
Das Ziel dieses Dokuments ist die Beschreibung der Struktur ....
1.3 Hierarchie der Implementierungsleitfäden
Der vorliegende Implementierungsleitfaden basiert auf der grundlegenden Implementierungsvorschrift für alle CDA Dokumente im österreichischen Gesundheitswesen.
Das CDA Dokument "Patient Summary" hat grundsätzlich beiden aufeinander aufbauenden Implementierungsleitfäden zu folgen.
Die administrativen Daten im Dokumentheader und grundsätzliche Vorgaben für den medizinischen Inhalt werden vom "Allgemeinen Implementierungsleitfaden" definiert. Der jeweilige "Spezielle Implementierungsleitfaden" enthält die Vorgaben für die medizinischen Inhalte und ergänzt gegebenenfalls die Header-Vorgaben.
| Für die Verwendung dieses Implementierungsleitfadens sind zusätzlich die Vorgaben aus "HL7 Implementation Guide for CDA® R2: Allgemeiner Implementierungsleitfaden für ELGA CDA Dokumente" [OID Root 1.2.40.0.34.7.1] |
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