1.2.40.0.34.11.13.2.1/static-2016-11-10T203916

Id	1.2.40.0.34.11.13.2.1	Gültigkeit	2016‑11‑10 20:39:16
Status	Entwurf	Versions-Label	0.1
Name	AllergienUnvertraeglichkeiten	Anzeigename	Allergien und Intoleranzen
Beschreibung Diese Sektion enthält relevante Allergien oder Intoleranzen des Patienten. Angegeben werden die Art der Reaktion (Hautausschlag, Anaphylaxie, Erbrechen, ...), vorzugsweise die auslösende Substanz, die Kritikalität sowie eine Angabe, wie gesichert die Information ist. Grundsätzlich sollen nur relevante Allergien und Intoleranzen angeführt werden. Wenn keine relevanten Allergien oder Intoleranzen vorliegen oder keine Information verfügbar ist, soll das klar erkennbar dokumentiert werden. Nicht relevante Intoleranzen oder Allergien sollen nicht angegeben werden.  Alle enthaltenen Informationen MÜSSEN auch maschinenlesbar verfügbar sein, wenn keine Informationen vorliegen, ist das ebenfalls mit einem Code auszudrücken.
Kontext	Elternknoten des Template-Element mit Id 1.2.40.0.34.11.13.2.1
Klassifikation	CDA Section level template
Offen/Geschlossen	Offen (auch andere als die definierten Elemente sind erlaubt)
Benutzt von / Benutzt	Benutzt von 0 Transactions und 1 Template, Benutzt 3 Templates Benutzt von als Name Version 1.2.40.0.34.11.13 Containment CDA ELGA Patient Summary (0.1) 2016‑08‑30 16:19:25 Benutzt als Name Version 1.2.40.0.34.11.13.3.16 Containment Author (Body) PS DYNAMIC 1.2.40.0.34.11.13.3.20 Containment Informant (Body) PS (0.1) DYNAMIC 1.2.40.0.34.11.13.3.1 Containment Allergien und Intoleranzen Entry (0.1) DYNAMIC
Beispiel	Strukturbeispiel <section>   <templateId root="1.2.40.0.34.11.13.2.1"/>  <code code="48765-2" displayName="Allergies, adverse reactions, alerts" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <title>Allergien und Unverträglichkeiten</title>  <text/>  <author>     <!-- template 1.2.40.0.34.11.13.3.16 'Author (Body) PS' (dynamic) -->   </author>  <informant>     <!-- template 1.2.40.0.34.11.13.3.20 'Informant (Body) PS' (dynamic) -->   </informant>  <entry typeCode="DRIV">     <!-- template 1.2.40.0.34.11.13.3.1 'Allergien und Unverträglichkeiten Entry' (dynamic) -->   </entry></section>
Beispiel	Vollständig <section>   <templateId root="1.2.40.0.34.11.13.2.1"/>  <code code="48765-2" displayName="Allergies, adverse reactions, alerts" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <title>Allergien und Unverträglichkeiten</title>  <text>     <table>       <tr>         <th>Auslösende Substanz</th>        <th>Überempfindlichkeit</th>        <th/>      </tr>      <tr>         <td ID="alg1">Metamizol</td>        <td ID="typ1">Allergie</td>        <td>           <ul>             <li>Bekannt seit 2013-04</li>            <li>               <content ID="react1">Reaktion: Larynxödem</content>              (               <content ID="sev1">Schweregrad: mittel</content>              )            </li>            <li ID="crit1">Lebensbedrohlich</li>            <li ID="cert1">Diagnosesicherheit: bestätigt</li>            <li ID="status1">klinischer Status: bestehend</li>            <li ID="auth1">Author: Dr.Isabella Stern</li>            <li ID="doc1">Quelle: Ärztlicher Entlassungsbrief 2015-03-18 Amadeus Spital Salzburg</li>          </ul>        </td>      </tr>      <tr>         <td ID="alg2">Erdnuss (Arachis hypogaea)</td>        <td ID="typ2">Intoleranz</td>        <td>           <ul>             <li>Bekannt seit 2002-12</li>            <li>               <content ID="react2">Reaktion: Durchfall</content>              (               <content ID="sev2">Schweregrad: mittel</content>              )            </li>            <li>               <content ID="react3">Reaktion: Urtikaria</content>              (               <content ID="sev3">Schweregrad: schwer</content>              )            </li>            <li ID="crit2">Nicht Lebensbedrohlich</li>            <li ID="cert2">Diagnosesicherheit: bestätigt</li>            <li ID="status2">klinischer Status: bestehend</li>            <li>Informant: Eigenangabe des Patienten</li>          </ul>        </td>      </tr>      <tr>         <td ID="alg3">Schokolade</td>        <td ID="typ3">Überempfindlichkeit</td>        <td>(keine weiteren Details)</td>      </tr>    </table>  </text>  <entry typeCode="DRIV">     <!-- template 1.2.40.0.34.11.13.3.1 'Allergien und Unverträglichkeiten Entry' (dynamic) -->     <act>       <templateId root="1.2.40.0.34.11.13.3.1"/>      <id root="1.2.3.999" extension="--example only--"/>      <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>      <statusCode code="active"/>      <effectiveTime>         <low value="20130400"/>      </effectiveTime>      <author typeCode="AUT" contextControlCode="OP">         <!-- template 1.2.40.0.34.11.13.3.16 'Author (Body) PS' (2017-08-05T19:04:45) -->         <time value="UNK"/>        <assignedAuthor classCode="ASSIGNED">           <id root="1.2.3.999" extension="--example only--"/>          <code code="107" displayName="Fachärztin/Facharzt für Chirurgie" codeSystem="1.2.40.0.34.5.160" codeSystemName="ELGA_Fachaerzte"/>          <assignedPerson classCode="PSN" determinerCode="INSTANCE">             <name>               <prefix qualifier="AC">Univ.Prof. Dr.</prefix>              <given>Isabella</given>              <family>Stern</family>            </name>          </assignedPerson>        </assignedAuthor>      </author>      <entryRelationship typeCode="SUBJ" inversionInd="false">         <observation classCode="OBS" moodCode="EVN">           <!-- template 1.2.40.0.34.11.13.3.2 'Problem Entry Allergien ' (2016-11-06T17:03:02) -->           <templateId root="1.2.40.0.34.11.13.3.2"/>          <id root="1.2.3.999" extension="--example only--"/>          <!-- ValueSet ELGA_AllergyOrIntoleranceType 1.2.40.0.34.10.177 -->           <code code="419199007" displayName="Allergy to substance" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>          <text>             <reference value="#typ1"/>          </text>          <statusCode code="completed"/>          <effectiveTime>             <low value="20130400"/>          </effectiveTime>          <participant>             <participantRole classCode="MANU">               <playingEntity classCode="MMAT">                 <!-- ValueSet ELGA_AllergyOrIntoleranceAgent 1.2.40.0.34.10.180 -->                 <code code="1708977" displayName="METAMIZOL NATRIUM" codeSystem="1.2.40.0.34.5.156" codeSystemName="Medikation_AGES_Wirkstoffe _20170725">                   <originalText>                     <reference value="#alg1"/>                  </originalText>                </code>              </playingEntity>            </participantRole>          </participant>          <entryRelationship inversionInd="true" typeCode="MFST">             <observation classCode="OBS" moodCode="EVN">               <!-- template 1.2.40.0.34.11.13.3.15 'Problem Entry Allergien-Reaktion' (2017-07-13T21:39:19) -->               <templateId root="1.2.40.0.34.11.13.3.15"/>              <id root="1.2.3.999" extension="--example only--"/>              <!-- ValueSet ELGA_Problemarten_2018 -->               <code code="75326-9" displayName="Problem" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>              <statusCode code="completed"/>              <effectiveTime>                 <low nullFlavor="UNK"/>              </effectiveTime>              <value code="51599000" displayName="Oedema of larynx" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">                 <originalText>                   <reference value="#react1"/>                </originalText>              </value>              <entryRelationship typeCode="SUBJ" inversionInd="true">                 <observation classCode="OBS" moodCode="EVN">                   <!-- template 1.2.40.0.34.11.13.3.21 'Severity Observation' (2017-08-20T12:08:35) -->                   <templateId root="1.2.40.0.34.11.13.3.21"/>                  <id root="1.2.3.999" extension="--example only--"/>                  <code code="SEV"/>                  <statusCode code="completed"/>                  <!-- ValueSet ELGA_ProblemSeverity 1.2.40.0.34.10.189 -->                   <value hl7:type="CD" code="6736007" displayName="Moderate" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">                     <originalText>                       <reference value="#sev1"/>                    </originalText>                  </value>                </observation>              </entryRelationship>            </observation>          </entryRelationship>          <entryRelationship typeCode="SUBJ" inversionInd="true">             <observation classCode="OBS" moodCode="EVN">               <!-- template 1.2.40.0.34.11.13.3.18 'Criticality Observation' (2017-08-10T19:52:16) -->               <templateId root="1.2.40.0.34.11.13.3.18"/>              <code code="82606-5" codeSystem="2.16.840.1.113883.6.1"/>              <statusCode code="completed"/>              <!-- ValueSet ELGA_CriticalityObservationValue 1.2.40.0.34.10.182 -->               <value hl7:type="CD" code="CRITH" displayName="High criticality" codeSystem="2.16.840.1.113883.5.1063" codeSystemName="Observation Value">                 <originalText>                   <reference value="#crit1"/>                </originalText>              </value>            </observation>          </entryRelationship>          <entryRelationship typeCode="SUBJ" inversionInd="true">             <observation classCode="OBS" moodCode="EVN">               <!-- template 1.2.40.0.34.11.13.3.19 'Certainty Observation' (2017-08-10T20:25:54) -->               <templateId root="1.2.40.0.34.11.13.3.19"/>              <!-- LOINC Code not yet defined -->               <code code="NEW-LOINC-CERTAINTY" displayName="NEW-LOINC-CERTAINTY" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>              <statusCode code="completed"/>              <!-- ValueSet ELGA_ConditionVerificationStatus 1.2.40.0.34.10.184 -->               <value hl7:type="CD" code="confirmed" displayName="confirmed" codeSystem="2.16.840.1.113883.4.642.3.115" codeSystemName="AllergyIntoleranceVerificationStatus">                 <originalText>                   <reference value="#cert1"/>                </originalText>              </value>            </observation>          </entryRelationship>          <entryRelationship typeCode="REFR" inversionInd="false">             <observation classCode="OBS" moodCode="EVN">               <!-- template 1.2.40.0.34.11.13.3.14 'Allergy Status Observation' (2017-07-13T21:15:15) -->               <templateId root="1.2.40.0.34.11.13.3.14"/>              <code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>              <statusCode code="completed"/>              <!-- ValueSet ELGA_AllergyStatusCode 1.2.40.0.34.10.183 -->               <value hl7:type="CD" code="active" displayName="active" codeSystem="2.16.840.1.113883.4.642.3.155" codeSystemName="Condition Clinical Status Codes"/>              <originalText>                 <reference value="#status1"/>              </originalText>            </observation>          </entryRelationship>        </observation>      </entryRelationship>      <reference>         <externalDocument classCode="DOC" moodCode="EVN">           <!-- template 1.2.40.0.34.11.13.3.17 'ELGA ExternalDocument' (2017-08-09T10:55:40) -->           <id root="1.2.3.999" extension="--example only--"/>          <!-- ValueSet HL7-at_XDS-Dokumentenklassen -->           <code code="11490-0" displayName="Physician Discharge summary" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>          <text>             <reference value="#doc1"/>          </text>        </externalDocument>      </reference>    </act>  </entry>  <entry typeCode="DRIV">     <!-- template 1.2.40.0.34.11.13.3.1 'Allergien und Unverträglichkeiten Entry' (dynamic) -->     <act>       <templateId root="1.2.40.0.34.11.13.3.1"/>      <id root="1.2.3.999" extension="--example only--"/>      <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>      <statusCode code="active"/>      <effectiveTime>         <low value="20021200"/>      </effectiveTime>      <informant>         <!-- template 1.2.40.0.34.11.13.3.20 'Informant (Body) PS' (2017-08-10T20:49:25) -->         <relatedEntity classCode="PRS">           <code code="SELF" displayName="self" codeSystem="1.2.40.0.34.10.17" codeSystemName="ELGA_PersonalRelationship"/>        </relatedEntity>      </informant>      <entryRelationship typeCode="SUBJ" inversionInd="false">         <observation classCode="OBS" moodCode="EVN">           <!-- template 1.2.40.0.34.11.13.3.2 'Problem Entry Allergien ' (2016-11-06T17:03:02) -->           <id root="1.2.3.999" extension="--example only--"/>          <code code="X-Intolerance" displayName="Intolerance to substance" codeSystem="2.16.840.1.113883.3.1937.777.13.5.999.1" codeSystemName="hl7ips-codesystem"/>          <text>             <reference value="#typ2"/>          </text>          <statusCode code="completed"/>          <effectiveTime>             <low value="20021200"/>          </effectiveTime>          <participant>             <!-- template 1.2.40.0.34.11.13.3.3 'Participant Allergie' (2016-11-06T17:53:23) -->             <participantRole classCode="MANU">               <playingEntity classCode="MMAT">                 <!-- ValueSet ELGA_AllergyOrIntoleranceAgent 1.2.40.0.34.10.180 -->                 <code code="256349002" displayName="Peanut - dietary" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">                   <originalText>                     <reference value="#alg2"/>                  </originalText>                </code>              </playingEntity>            </participantRole>          </participant>          <entryRelationship typeCode="MFST" inversionInd="true">             <observation classCode="OBS" moodCode="EVN">               <!-- template 1.2.40.0.34.11.13.3.15 'Problem Entry Allergien-Reaktion' (2017-07-13T21:39:19) -->               <templateId root="1.2.40.0.34.11.13.3.15"/>              <id root="1.2.3.999" extension="--example only--"/>              <!-- ValueSet ELGA_Problemarten_2018 -->               <code code="75326-9" displayName="Problem" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>              <statusCode code="completed"/>              <effectiveTime>                 <low nullFlavor="UNK"/>              </effectiveTime>              <!-- ValueSet ELGA_AllergyReaction 1.2.40.0.34.10.181 -->               <value code="62315008" displayName="Diarrhoea" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">                 <originalText>                   <reference value="#react2"/>                </originalText>                <translation/>              </value>              <entryRelationship typeCode="SUBJ" inversionInd="true">                 <observation classCode="OBS" moodCode="EVN">                   <!-- template 1.2.40.0.34.11.13.3.21 'Severity Observation' (2017-08-20T12:08:35) -->                   <templateId root="1.2.40.0.34.11.13.3.21"/>                  <id root="1.2.3.999" extension="--example only--"/>                  <code code="SEV"/>                  <statusCode code="completed"/>                  <!-- ValueSet ELGA_ProblemSeverity 1.2.40.0.34.10.189 -->                   <value hl7:type="CD" code="6736007" displayName="Moderate" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">                     <originalText>                       <reference value="#sev2"/>                    </originalText>                  </value>                </observation>              </entryRelationship>            </observation>            <observation classCode="OBS" moodCode="EVN">               <!-- template 1.2.40.0.34.11.13.3.15 'Problem Entry Allergien-Reaktion' (2017-07-13T21:39:19) -->               <templateId root="1.2.40.0.34.11.13.3.15"/>              <id root="1.2.3.999" extension="--example only--"/>              <!-- ValueSet ELGA_Problemarten_2018 -->               <code code="75326-9" displayName="Problem" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>              <statusCode code="completed"/>              <effectiveTime>                 <low nullFlavor="UNK"/>              </effectiveTime>              <!-- ValueSet ELGA_AllergyReaction 1.2.40.0.34.10.181 -->               <value code="126485001" displayName="Urticaria" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">                 <originalText>                   <reference value="#react3"/>                </originalText>              </value>              <entryRelationship typeCode="SUBJ" inversionInd="true">                 <observation classCode="OBS" moodCode="EVN">                   <!-- template 1.2.40.0.34.11.13.3.21 'Severity Observation' (2017-08-20T12:08:35) -->                   <templateId root="1.2.40.0.34.11.13.3.21"/>                  <id root="1.2.3.999" extension="--example only--"/>                  <code code="SEV"/>                  <statusCode code="completed"/>                  <!-- ValueSet ELGA_ProblemSeverity 1.2.40.0.34.10.189 -->                   <value hl7:type="CD" code="24484000" displayName="Severe" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">                     <originalText>                       <reference value="#sev3"/>                    </originalText>                  </value>                </observation>              </entryRelationship>            </observation>          </entryRelationship>          <entryRelationship typeCode="SUBJ" inversionInd="true">             <observation classCode="OBS" moodCode="EVN">               <!-- template 1.2.40.0.34.11.13.3.18 'Criticality Observation' (2017-08-10T19:52:16) -->               <templateId root="1.2.40.0.34.11.13.3.18"/>              <code code="82606-5" codeSystem="2.16.840.1.113883.6.1"/>              <statusCode code="completed"/>              <!-- ValueSet ELGA_CriticalityObservationValue 1.2.40.0.34.10.182 -->               <value hl7:type="CD" code="CRITL" codeSystem="2.16.840.1.113883.5.1063" codeSystemName="Observation Value">                 <originalText>                   <reference value="#crit2"/>                </originalText>              </value>            </observation>          </entryRelationship>          <entryRelationship typeCode="SUBJ" inversionInd="true">             <observation classCode="OBS" moodCode="EVN">               <!-- template 1.2.40.0.34.11.13.3.19 'Certainty Observation' (2017-08-10T20:25:54) -->               <templateId root="1.2.40.0.34.11.13.3.19"/>              <code code="t.b.d.NEW-LOINC-CERTAINTY" codeSystem="2.16.840.1.113883.6.1"/>              <statusCode code="completed"/>              <!-- ValueSet ELGA_ConditionVerificationStatus 1.2.40.0.34.10.184 -->               <value hl7:type="CD" code="confirmed" displayName="confirmed" codeSystem="2.16.840.1.113883.4.642.3.115" codeSystemName="AllergyIntoleranceVerificationStatus">                 <originalText>                   <reference value="#cert2"/>                </originalText>              </value>            </observation>          </entryRelationship>          <entryRelationship typeCode="REFR" inversionInd="false">             <observation classCode="OBS" moodCode="EVN">               <!-- template 1.2.40.0.34.11.13.3.14 'Allergy Status Observation' (2017-07-13T21:15:15) -->               <templateId root="1.2.40.0.34.11.13.3.14"/>              <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>              <statusCode code="completed"/>              <!-- ValueSet ELGA_AllergyStatusCode 1.2.40.0.34.10.183 -->               <value hl7:type="CD" code="active" codeSystem="2.16.840.1.113883.4.642.3.155" codeSystemName="Condition Clinical Status Codes">                 <originalText>                   <reference value="#status2"/>                </originalText>              </value>            </observation>          </entryRelationship>        </observation>      </entryRelationship>    </act>  </entry>  <entry typeCode="DRIV">     <!-- template 1.2.40.0.34.11.13.3.1 'Allergien und Unverträglichkeiten Entry' (dynamic) -->     <act>       <templateId root="1.2.40.0.34.11.13.3.1"/>      <id root="1.2.3.999" extension="--example only--"/>      <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>      <statusCode code="active"/>      <effectiveTime>         <low nullFlavor="UNK"/>      </effectiveTime>      <entryRelationship typecode="SUBJ" inversionInd="false">         <observation classCode="OBS" moodCode="EVN">           <!-- template 1.2.40.0.34.11.13.3.2 'Problem Entry Allergien ' (2016-11-06T17:03:02) -->           <templateId root="1.2.40.0.34.11.13.3.2"/>          <id root="1.2.3.999" extension="--example only--"/>          <!-- ValueSet ELGA_AllergyOrIntoleranceType 1.2.40.0.34.10.177 -->           <code code="418038007" displayName="Propensity to adverse reactions to substance" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>          <text>             <reference value="#typ3"/>          </text>          <statusCode code="completed"/>          <effectiveTime>             <low nullFlavor="UNK"/>          </effectiveTime>          <participant>             <!-- template 1.2.40.0.34.11.13.3.3 'Participant Allergie' (2016-11-06T17:53:23) -->             <participantRole classCode="MANU">               <playingEntity classCode="MMAT">                 <!-- ValueSet ELGA_AllergyOrIntoleranceAgent 1.2.40.0.34.10.180 -->                 <code code="102262009" displayName="Chocolate" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">                   <originalText>                     <reference value="#alg3"/>                  </originalText>                </code>              </playingEntity>            </participantRole>          </participant>        </observation>      </entryRelationship>    </act>  </entry></section>
Item DT Kard Konf Beschreibung Label hl7:section 1 … 1 R (All...ten) hl7:templateId II 1 … 1 M (All...ten) @root uid 1 … 1 F 1.2.40.0.34.11.13.2.1 hl7:code CE (extensible) 1 … 1 M (All...ten) @code CONF 1 … 1 F 48765-2 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) @codeSystemName 1 … 1 F LOINC @displayName 1 … 1 F Allergies, adverse reactions, alerts   Beispiel <code code="48765-2" displayName="Allergies, adverse reactions, alerts" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> hl7:title ST 1 … 1 M (All...ten)   CONF Elementinhalt muss "Allergien und Intoleranzen" sein hl7:text SD.TEXT 1 … 1 M Der Text enthält relevante Allergien oder Intoleranzen des Patienten in tabellarischer Darstellung.  (All...ten) hl7:author 0 … * Author der enthaltenen Information (GDA) Beinhaltet 1.2.40.0.34.11.13.3.16 Author (Body) PS (DYNAMIC) (All...ten) wo [hl7:assignedAuthor] hl7:informant 0 … * Quelle der Information. Name der Person und ihre Beziehung zum Patienten (Patient oder Angehöriger, Auskunftsperson - nicht-GDA) Beinhaltet 1.2.40.0.34.11.13.3.20 Informant (Body) PS (DYNAMIC) (All...ten) hl7:entry 1 … * R Enthält die codierte Angabe der Allergien und Intoleranzen Beinhaltet 1.2.40.0.34.11.13.3.1 Allergien und Intoleranzen Entry (DYNAMIC) (All...ten) wo [hl7:act [hl7:code [(@code = 'CONC' and @codeSystem = '2.16.840.1.113883.5.6')]]] @typeCode cs 0 … 1 F DRIV