ILF:Ärztlicher Befund: Unterschied zwischen den Versionen
[unmarkierte Version] | [unmarkierte Version] |
(→Outpatient Report) |
(→Datenelemente) |
||
Zeile 45: | Zeile 45: | ||
==Datenelemente== | ==Datenelemente== | ||
+ | |||
+ | {| class="wikitable" | ||
+ | ! 51845-6 | ||
+ | ! Outpatient Consult note | ||
+ | ! Facharztbefund / Fachambulanzbefund | ||
+ | |- | ||
+ | | 34764-1 | ||
+ | | General medicine Consult note | ||
+ | | Allgemeinmedizinischer Befund | ||
+ | |- | ||
+ | | 24131-3 | ||
+ | | Outpatient Progress note | ||
+ | | „Statusbericht“ ( *** neu ***) | ||
+ | |- | ||
+ | | 34803-7 | ||
+ | | Occupational medicine Consult note | ||
+ | | Arbeitsmedizinischer Befund | ||
+ | |- | ||
+ | | 34807-8 | ||
+ | | Ophthalmology Consult note | ||
+ | | Augenbefund | ||
+ | |- | ||
+ | | 33720-4 | ||
+ | | Blood bank consult | ||
+ | | Immunhämatologischer Befund | ||
+ | |- | ||
+ | | 34847-4 | ||
+ | | Surgery Consult note | ||
+ | | Chirurgischer Befund | ||
+ | |- | ||
+ | | 34758-3 | ||
+ | | Dermatology Consult note | ||
+ | | Dermatologiebefund | ||
+ | |- | ||
+ | | 34760-9 | ||
+ | | Diabetology Consult note | ||
+ | | Diabetologischer Befund | ||
+ | |- | ||
+ | | 34879-7 | ||
+ | | Endocrinology Consult note | ||
+ | | Endokrinologiebefund | ||
+ | |- | ||
+ | | 34761-7 | ||
+ | | Gastroenterology Consult note | ||
+ | | Gastroenterologiebefund | ||
+ | |- | ||
+ | | 34853-2 | ||
+ | | Vascular surgery Consult note | ||
+ | | Gefäßchirurgischer Befund | ||
+ | |- | ||
+ | | 34776-5 | ||
+ | | Geriatric medicine Consult note | ||
+ | | Geriatriebefund | ||
+ | |- | ||
+ | | 34777-3 | ||
+ | | Obstetrics and Gynecology Consult note | ||
+ | | Gynäkologie-Befund | ||
+ | |- | ||
+ | | 34779-9 | ||
+ | | Hematology+Medical Oncology Consult note | ||
+ | | Hämatologie-Befund | ||
+ | |- | ||
+ | | 34816-9 | ||
+ | | Otolaryngology Consult note | ||
+ | | HNO-Befund | ||
+ | |- | ||
+ | | 34781-5 | ||
+ | | Infectious disease Consult note | ||
+ | | Infektiologiebefund | ||
+ | |- | ||
+ | | 34099-2 | ||
+ | | Cardiology Consult note | ||
+ | | Kardiologiebefund | ||
+ | |- | ||
+ | | 68881-2 | ||
+ | | Pediatric surgery Note | ||
+ | | Kinder- und Jugendchirurgischer Befund | ||
+ | |- | ||
+ | | 34812-8 | ||
+ | | Oral and Maxillofacial Surgery Consult note | ||
+ | | Mund-, Kiefer- und Gesichtschirurgischer Befund | ||
+ | |- | ||
+ | | 34795-5 | ||
+ | | Nephrology Consult note | ||
+ | | Nephrologischer befund | ||
+ | |- | ||
+ | | 34798-9 | ||
+ | | Neurological surgery Consult note | ||
+ | | Neurochirurgischer Befund | ||
+ | |- | ||
+ | | 34797-1 | ||
+ | | Neurology Consult note | ||
+ | | Neurologischer Befund | ||
+ | |- | ||
+ | | 34805-2 | ||
+ | | Oncology Consult note | ||
+ | | Onkologiebefund | ||
+ | |- | ||
+ | | 34814-4 | ||
+ | | Orthopaedic surgery Consult note | ||
+ | | Orthopädischer/Orthopädisch-Chirurgischer Befund | ||
+ | |- | ||
+ | | 68818-4 | ||
+ | | Pediatrics Note | ||
+ | | Pädiatrischer Befund | ||
+ | |- | ||
+ | | 34822-7 | ||
+ | | Physical medicine and rehabilitation Consult note | ||
+ | | Physikalisch-Medizinischer Befund | ||
+ | |- | ||
+ | | 34826-8 | ||
+ | | Plastic surgery Consult note | ||
+ | | Plastisch-Chirurgischer Befund | ||
+ | |- | ||
+ | | 34788-0 | ||
+ | | Psychiatry Consult note | ||
+ | | Psychiatrischer Befund | ||
+ | |- | ||
+ | | 34103-2 | ||
+ | | Pulmonary Consult note | ||
+ | | Pulmologischer Befund | ||
+ | |- | ||
+ | | 34839-1 | ||
+ | | Rheumatology Consult note | ||
+ | | Rheumatologischer Befund | ||
+ | |- | ||
+ | | 34831-8 | ||
+ | | Radiation oncology Consult note | ||
+ | | Strahlentherapeutisch-Radioonkologischer Befund | ||
+ | |- | ||
+ | | 34849-0 | ||
+ | | Thoracic surgery Consult note | ||
+ | | Thoraxchirurgischer Befund | ||
+ | |- | ||
+ | | 34851-6 | ||
+ | | Urology Consult note | ||
+ | | Urologischer Befund | ||
+ | |} | ||
==Art-Decor== | ==Art-Decor== |
Version vom 19. Juli 2017, 09:18 Uhr
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{{#switch: {{#if: | | {{#if: | {{#ifeq:| | talk | }} | {{#ifeq:ilf|ilf diskussion | talk | ilf }} }} }}
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| text = Diese Seite oder Abschnitt ist derzeit ein Entwurf und kann sich noch ändern.
This {{#switch:
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}} was last edited by Sabutsch ({{#if:talk|talk}}{{#if:contribs| | contribs}}{{#if:| | {{{3}}}}}{{#if:| | {{{4}}}}}{{#if:| | {{{5}}}}}{{#if:| | {{{6}}}}}{{#if:| | {{{7}}}}}{{#if:| | {{{8}}}}}{{#if:| | {{{9}}}}}{{#if:| | {{{10}}}}}{{#if:| | {{{11}}}}}{{#if:| | {{{12}}}}}{{#if:| | {{{13}}}}}{{#if:| | {{{14}}}}}{{#if:| | {{{15}}}}}{{#if:| | {{{16}}}}}{{#if:| | {{{17}}}}}{{#if:| | {{{18}}}}}{{#if:| | {{{19}}}}}{{#if:| | {{{20}}}}}) {{#iferror: {{#time:U| 20170719091841 }}
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|{{{magnitude}}} |{{{min_magnitude}}} }} |years = 6 |months = 5 |weeks = 4 |days = 3 |hours = 2 |minutes = 1 |seconds |#default= 0 }}|{{#expr:{{#if:{{#if: |0 |{{#expr:{{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 120 ) | 1 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 7200 ) | 1 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 172800 ) | 1 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 5356800 ) | 2 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 63115200 ) | 1 | 0 }} }} }}|{{#if:|{{#ifexpr:({{#switch:{{#if: |{{{magnitude}}} |{{{min_magnitude}}} }} |years = 6 |months = 5 |weeks = 4 |days = 3 |hours = 2 |minutes = 1 |seconds |#default= 0 }})>({{#if: |0 |{{#expr:{{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 120 ) | 1 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 7200 ) | 1 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 172800 ) | 1 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 5356800 ) | 2 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 63115200 ) | 1 | 0 }} }} }})|{{#ifexpr:({{#switch:{{#if: |{{{magnitude}}} |{{{min_magnitude}}} }} |years = 6 |months = 5 |weeks = 4 |days = 3 |hours = 2 |minutes = 1 |seconds |#default= 0 }})>({{{3}}})|{{#switch:{{#if: |{{{magnitude}}} |{{{min_magnitude}}} }} |years = 6 |months = 5 |weeks = 4 |days = 3 |hours = 2 |minutes = 1 |seconds |#default= 0 }}|{{{3}}}}}|{{#ifexpr:({{#if: |0 |{{#expr:{{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 120 ) | 1 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 7200 ) | 1 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 172800 ) | 1 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 5356800 ) | 2 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 63115200 ) | 1 | 0 }} }} }})>({{{3}}})|{{#if: |0 |{{#expr:{{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 120 ) | 1 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 7200 ) | 1 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 172800 ) | 1 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 5356800 ) | 2 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 63115200 ) | 1 | 0 }} }} }}|{{{3}}}}}}}|{{#ifexpr:({{#switch:{{#if: |{{{magnitude}}} |{{{min_magnitude}}} }} |years = 6 |months = 5 |weeks = 4 |days = 3 |hours = 2 |minutes = 1 |seconds |#default= 0 }})>({{#if: |0 |{{#expr:{{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 120 ) | 1 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 7200 ) | 1 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 172800 ) | 1 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 5356800 ) | 2 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 63115200 ) | 1 | 0 }} }} }})|{{#switch:{{#if: |{{{magnitude}}} |{{{min_magnitude}}} }} |years = 6 |months = 5 |weeks = 4 |days = 3 |hours = 2 |minutes = 1 |seconds |#default= 0 }}|{{#if: |0 |{{#expr:{{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 120 ) | 1 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 7200 ) | 1 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 172800 ) | 1 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 5356800 ) | 2 | 0 }}+ {{#ifexpr: floor( abs( {{#time:U}} - {{#time:U| 20170719091841 }} ) / 63115200 ) | 1 | 0 }} }} }}}}}}|{{#switch:{{#if: |{{{magnitude}}} |{{{min_magnitude}}} }} |years = 6 |months = 5 |weeks = 4 |days = 3 |hours = 2 |minutes = 1 |seconds |#default= 0 }}}}}}|}} |0 = {{#expr:floor(abs({{#time:U}}-{{#time:U|20170719091841}}))}} seconds' |1 = {{#expr:floor(abs({{#time:U}}-{{#time:U|20170719091841}})/60)}} minutes' |2 = {{#expr:floor(abs({{#time:U}}-{{#time:U|20170719091841}})/3600)}} hours' |3 = {{#expr:floor(abs({{#time:U}}-{{#time:U|20170719091841}})/86400)}} days' |4 = {{#expr:floor(abs({{#time:U}}-{{#time:U|20170719091841}})/604800)}} weeks' |5 = {{#expr:floor(abs({{#time:U}}-{{#time:U|20170719091841}})/2678400)}} months' |6 = {{#expr:floor(abs({{#time:U}}-{{#time:U|20170719091841}})/31557600)}} years'
}} time }}
}}.This article or section is in the middle of an expansion or major restructuring.
This {{#switch:
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}} was last edited by Sabutsch ({{#if:talk|talk}}{{#if:contribs| | contribs}}{{#if:| | {{{3}}}}}{{#if:| | {{{4}}}}}{{#if:| | {{{5}}}}}{{#if:| | {{{6}}}}}{{#if:| | {{{7}}}}}{{#if:| | {{{8}}}}}{{#if:| | {{{9}}}}}{{#if:| | {{{10}}}}}{{#if:| | {{{11}}}}}{{#if:| | {{{12}}}}}{{#if:| | {{{13}}}}}{{#if:| | {{{14}}}}}{{#if:| | {{{15}}}}}{{#if:| | {{{16}}}}}{{#if:| | {{{17}}}}}{{#if:| | {{{18}}}}}{{#if:| | {{{19}}}}}{{#if:| | {{{20}}}}}) {{#iferror: {{#time:U| 20170719091841 }}
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Dieses Dokument gibt wieder:
Implementierungsleitfaden Outpatient Report {{#if: 0.01| (0.01)|}}, OID: n.n., Datum: 18. Juli 2017, Status: Entwurf. Die Teilmaterialien gehören der Kategorie elga-cdaopr-2.06.2 an. |
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Implementierungsleitfäden
Outpatient Report
Gesundheitswesen [1.2.40.0.34.11.14.x.x]
Inhaltsverzeichnis
1 Outpatient Report
1.1 Allgemeines
Patientenzentrierte medizinische Dokumente aus dem (fach-) ärztlichen Bereich oder aus (Fach-) Ambulanzen zum Austausch zwischen GDA-Organisationen und für den Patient zur eigenen Verwendung Das Dokument wird durch einen GDA am Ende einer oder mehrerer Patientenkontakte / Konsultationen (persönlich oder telemedizinisch) erstellt Beispiele: Befunde, Briefe, Berichte, Statusberichte, …
1.2 Definition
Outpatient Report Dokumente
- sind das Ergebnis einer Behandlung
- werden von Ärzten erstellt und haben einen Hauptverantwortlichen
- entstehen zu dem Zeitpunkt, an dem für den Patienten oder die Nachbehandler eine relevante Information entsteht. Die Entscheidung ist * dem erstellenden GDA überlassen
- Die Erstellung ist auch erst nach mehreren Patientenkontakten möglich, v.a. bei vielen ambulanten Besuchen in kurzen Abständen.
- Gegebenenfalls können bei mehreren Kontakten auch mehrere zusammengehörige Dokumente entstehen, die dann als BefundVERSIONEN (eines Befundes) registriert werden sollen, so kann die Anzahl an Befunden reduziert werden (zB Ergänzung mit neuen Messwerten).
- Detaillierungsgrad und Häufigkeit der Entstehung werden durch den erstellenden GDA festgelegt.
sind patientenzentriert und sollen dem Patienten und allen weiteren (berechtigten) Behandlern zur Verfügung stehen
1.3 Datenelemente
51845-6 | Outpatient Consult note | Facharztbefund / Fachambulanzbefund |
---|---|---|
34764-1 | General medicine Consult note | Allgemeinmedizinischer Befund |
24131-3 | Outpatient Progress note | „Statusbericht“ ( *** neu ***) |
34803-7 | Occupational medicine Consult note | Arbeitsmedizinischer Befund |
34807-8 | Ophthalmology Consult note | Augenbefund |
33720-4 | Blood bank consult | Immunhämatologischer Befund |
34847-4 | Surgery Consult note | Chirurgischer Befund |
34758-3 | Dermatology Consult note | Dermatologiebefund |
34760-9 | Diabetology Consult note | Diabetologischer Befund |
34879-7 | Endocrinology Consult note | Endokrinologiebefund |
34761-7 | Gastroenterology Consult note | Gastroenterologiebefund |
34853-2 | Vascular surgery Consult note | Gefäßchirurgischer Befund |
34776-5 | Geriatric medicine Consult note | Geriatriebefund |
34777-3 | Obstetrics and Gynecology Consult note | Gynäkologie-Befund |
34779-9 | Hematology+Medical Oncology Consult note | Hämatologie-Befund |
34816-9 | Otolaryngology Consult note | HNO-Befund |
34781-5 | Infectious disease Consult note | Infektiologiebefund |
34099-2 | Cardiology Consult note | Kardiologiebefund |
68881-2 | Pediatric surgery Note | Kinder- und Jugendchirurgischer Befund |
34812-8 | Oral and Maxillofacial Surgery Consult note | Mund-, Kiefer- und Gesichtschirurgischer Befund |
34795-5 | Nephrology Consult note | Nephrologischer befund |
34798-9 | Neurological surgery Consult note | Neurochirurgischer Befund |
34797-1 | Neurology Consult note | Neurologischer Befund |
34805-2 | Oncology Consult note | Onkologiebefund |
34814-4 | Orthopaedic surgery Consult note | Orthopädischer/Orthopädisch-Chirurgischer Befund |
68818-4 | Pediatrics Note | Pädiatrischer Befund |
34822-7 | Physical medicine and rehabilitation Consult note | Physikalisch-Medizinischer Befund |
34826-8 | Plastic surgery Consult note | Plastisch-Chirurgischer Befund |
34788-0 | Psychiatry Consult note | Psychiatrischer Befund |
34103-2 | Pulmonary Consult note | Pulmologischer Befund |
34839-1 | Rheumatology Consult note | Rheumatologischer Befund |
34831-8 | Radiation oncology Consult note | Strahlentherapeutisch-Radioonkologischer Befund |
34849-0 | Thoracic surgery Consult note | Thoraxchirurgischer Befund |
34851-6 | Urology Consult note | Urologischer Befund |
1.4 Art-Decor
1.4.1 Art-Decor Data Set
1.4.2 Art-Decor
In Arbeit https://art-decor.org/art-decor/decor-templates--elga-?section=templates
1.5 Status
In Arbeit