1.2.40.0.34.6.0.11.3.31/static-2023-02-02T154005: 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;">1.2.40.0.34.6.0.11.3.31 <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</div></span></td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2023‑02‑02 15:40:05<div>Andere Versionen mit dieser Id:<ul><li>[[File:Kblank.png|14px]] elgagab_entry_KonsultationsgrundProblem vom  2022‑06‑02 15:20:46</li><li>[[File:Kblank.png|14px]] elgagab_entry_KonsultationsgrundProblem vom  2021‑08‑10 08:43:36</li><li>[[File:Kblank.png|14px]] elgagab_entry_KonsultationsgrundProblem vom  2021‑02‑19 10:46:53</li><li>[[File:Kblank.png|14px]] elgagab_entry_KonsultationsgrundProblem vom  2020‑11‑05 15:01:55</li><li>[[File:Kblank.png|14px]] elgagab_entry_KonsultationsgrundProblem vom  2018‑11‑20 09:56:38</li></ul></div></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;">1.1.3</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">elgagab_entry_KonsultationsgrundProblem</td><th style="width: 20em; text-align: left;">Bezeichnung</th><td style="text-align: left;">Konsultationsgrund Problem Entry</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>Mit dieser Observation wird ein bekanntes relevantes Gesundheitsproblem des Patienten codiert dargestellt.<br />Die Zeitspanne, in der ein Gesundheitsproblem besteht oder bestanden hat, wird hier angegeben.  </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 1.2.40.0.34.6.0.11.3.31</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Entry Level Template<br />Template-Typ nicht spezifiziert</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;">Benutzt</th><td style="text-align: left;" colspan="3"><table width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Benutzt 12 Templates</td></tr><tr><td><div><table width="100%" border="0" cellspacing="1" cellpadding="3" class="artdecor " style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Benutzt</th><th style="width: 1%; text-align: left;"> als </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.1</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Narrative Text Reference (1.0.1+20210512)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.2</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Original Text Reference (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.42</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Laterality Qualifier (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.17</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Performer Body (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.36</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Author Body (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.3</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Informant Body (1.0.1+20211213)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.13</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Participant Body (1.0.1+20210628)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.11</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Comment Entry (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.38</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Severity Observation (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.35</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Criticality Observation (1.0.1+20210628)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.36</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Certainty Observation (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.49</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Problem Status Observation (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beziehung</th><td style="text-align: left;" colspan="3">Version: Template 1.2.40.0.34.6.0.11.3.31 <i>Konsultationsgrund Problem Entry </i> (2022‑06‑02 15:20:46) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</div></span><br />Version: Template 1.2.40.0.34.6.0.11.3.31 <i>Konsultationsgrund Problem Entry </i> (2021‑08‑10 08:43:36) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</div></span><br />Version: Template 1.2.40.0.34.6.0.11.3.31 <i>Konsultationsgrund Problem Entry </i> (2021‑02‑19 10:46:53) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</div></span><br />Version: Template 1.2.40.0.34.6.0.11.3.31 <i>Konsultationsgrund Problem Entry </i> (2020‑11‑05 15:01:55) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</div></span><br />Version: Template 1.2.40.0.34.6.0.11.3.31 <i>Konsultationsgrund Problem Entry </i> (2018‑11‑20 09:56:38) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</div></span><br />Adaptation: Template 1.2.40.0.34.6.0.11.3.6 <i>Problem Entry </i> (DYNAMIC) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</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">Strukturbeispiel</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">observation</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">OBS</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="ppattribute">negationInd</span><span class="ppsign">="</span><span class="ppcontent">false</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">1.2.40.0.34.6.0.11.3.31</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">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.10.20.1.28</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">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.5.3.1.4.5</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">id</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">55607006</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.96</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Problem (finding)</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- include template 1.2.40.0.34.6.0.11.9.1 'Narrative Text Reference' (dynamic) 1..1 M --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">completed</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">effectiveTime</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">2019</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- choice: 1..1 <br />    element hl7:value[not(@nullFlavor)]<br />    element hl7:value[@nullFlavor='OTH']<br />    element hl7:value[@nullFlavor='NA']<br /> --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">targetSiteCode</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.2.40.0.34.6.0.11.9.42 'Laterality Qualifier' (2020-02-20T09:00:36) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">targetSiteCode</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">performer</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.2.40.0.34.6.0.11.9.17 'Performer Body' (2019-01-17T12:44:16) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">performer</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">author</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.2.40.0.34.6.0.11.9.36 'Author Body' (2019-11-20T12:13:04) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">author</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">informant</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.2.40.0.34.6.0.11.9.3 'Informant Body' (2019-02-07T13:29:32) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">informant</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">participant</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.2.40.0.34.6.0.11.9.13 'Participant Body' (2019-04-03T12:08:16) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">participant</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</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 1.2.40.0.34.6.0.11.3.11 'Comment Entry' (2019-02-07T13:10:44) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">SUBJ</span><span class="ppsign">"</span> <span class="ppattribute">inversionInd</span><span class="ppsign">="</span><span class="ppcontent">true</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 1.2.40.0.34.6.0.11.3.38 'Severity Observation' (2019-11-21T09:31:57) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">SUBJ</span><span class="ppsign">"</span> <span class="ppattribute">inversionInd</span><span class="ppsign">="</span><span class="ppcontent">true</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 1.2.40.0.34.6.0.11.3.35 'Criticality Observation' (2019-11-21T09:04:18) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">SUBJ</span><span class="ppsign">"</span> <span class="ppattribute">inversionInd</span><span class="ppsign">="</span><span class="ppcontent">true</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 1.2.40.0.34.6.0.11.3.36 'Certainty Observation' (2019-11-21T09:11:18) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">REFR</span><span class="ppsign">"</span> <span class="ppattribute">inversionInd</span><span class="ppsign">="</span><span class="ppcontent">false</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 1.2.40.0.34.6.0.11.3.49 'Problem Status Observation' (2019-12-03T09:46:18) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">observation</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:observation<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">OBS</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>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</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;">@negationInd<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>bl</td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2">
+
<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;">1.2.40.0.34.6.0.11.3.31 <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</div></span></td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2023‑02‑02 15:40:05<div>Andere Versionen mit dieser Id:<ul><li>[[File:Kblank.png|14px]] elgagab_entry_KonsultationsgrundProblem vom  2022‑06‑02 15:20:46</li><li>[[File:Kblank.png|14px]] elgagab_entry_KonsultationsgrundProblem vom  2021‑08‑10 08:43:36</li><li>[[File:Kblank.png|14px]] elgagab_entry_KonsultationsgrundProblem vom  2021‑02‑19 10:46:53</li><li>[[File:Kblank.png|14px]] elgagab_entry_KonsultationsgrundProblem vom  2020‑11‑05 15:01:55</li><li>[[File:Kblank.png|14px]] elgagab_entry_KonsultationsgrundProblem vom  2018‑11‑20 09:56:38</li></ul></div></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;">1.1.3</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">elgagab_entry_KonsultationsgrundProblem</td><th style="width: 20em; text-align: left;">Bezeichnung</th><td style="text-align: left;">Konsultationsgrund Problem Entry</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>Mit dieser Observation wird ein bekanntes relevantes Gesundheitsproblem des Patienten codiert dargestellt.<br />Die Zeitspanne, in der ein Gesundheitsproblem besteht oder bestanden hat, wird hier angegeben.  </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 1.2.40.0.34.6.0.11.3.31</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Entry Level Template<br />Template-Typ nicht spezifiziert</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;">Benutzt</th><td style="text-align: left;" colspan="3"><table width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Benutzt 12 Templates</td></tr><tr><td><div><table width="100%" border="0" cellspacing="1" cellpadding="3" class="artdecor " style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Benutzt</th><th style="width: 1%; text-align: left;"> als </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.1</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Narrative Text Reference (1.0.1+20210512)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.2</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Original Text Reference (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.42</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Laterality Qualifier (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.17</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Performer Body (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.36</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Author Body (1.0.1+20230717)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.3</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Informant Body (1.0.1+20211213)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.13</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Participant Body (1.0.1+20210628)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.11</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Comment Entry (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.38</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Severity Observation (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.35</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Criticality Observation (1.0.1+20210628)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.36</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Certainty Observation (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.49</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Problem Status Observation (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beziehung</th><td style="text-align: left;" colspan="3">Version: Template 1.2.40.0.34.6.0.11.3.31 <i>Konsultationsgrund Problem Entry </i> (2022‑06‑02 15:20:46) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</div></span><br />Version: Template 1.2.40.0.34.6.0.11.3.31 <i>Konsultationsgrund Problem Entry </i> (2021‑08‑10 08:43:36) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</div></span><br />Version: Template 1.2.40.0.34.6.0.11.3.31 <i>Konsultationsgrund Problem Entry </i> (2021‑02‑19 10:46:53) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</div></span><br />Version: Template 1.2.40.0.34.6.0.11.3.31 <i>Konsultationsgrund Problem Entry </i> (2020‑11‑05 15:01:55) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</div></span><br />Version: Template 1.2.40.0.34.6.0.11.3.31 <i>Konsultationsgrund Problem Entry </i> (2018‑11‑20 09:56:38) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</div></span><br />Adaptation: Template 1.2.40.0.34.6.0.11.3.6 <i>Problem Entry </i> (DYNAMIC) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</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">Strukturbeispiel</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">observation</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">OBS</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="ppattribute">negationInd</span><span class="ppsign">="</span><span class="ppcontent">false</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">1.2.40.0.34.6.0.11.3.31</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">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.10.20.1.28</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">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.5.3.1.4.5</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">id</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">55607006</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.96</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Problem (finding)</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- include template 1.2.40.0.34.6.0.11.9.1 'Narrative Text Reference' (dynamic) 1..1 M --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">completed</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">effectiveTime</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">2019</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- choice: 1..1 <br />    element hl7:value[not(@nullFlavor)]<br />    element hl7:value[@nullFlavor='OTH']<br />    element hl7:value[@nullFlavor='NA']<br /> --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">targetSiteCode</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.2.40.0.34.6.0.11.9.42 'Laterality Qualifier' (2020-02-20T09:00:36) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">targetSiteCode</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">performer</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.2.40.0.34.6.0.11.9.17 'Performer Body' (2019-01-17T12:44:16) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">performer</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">author</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.2.40.0.34.6.0.11.9.36 'Author Body' (2019-11-20T12:13:04) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">author</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">informant</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.2.40.0.34.6.0.11.9.3 'Informant Body' (2019-02-07T13:29:32) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">informant</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">participant</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.2.40.0.34.6.0.11.9.13 'Participant Body' (2019-04-03T12:08:16) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">participant</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</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 1.2.40.0.34.6.0.11.3.11 'Comment Entry' (2019-02-07T13:10:44) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">SUBJ</span><span class="ppsign">"</span> <span class="ppattribute">inversionInd</span><span class="ppsign">="</span><span class="ppcontent">true</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 1.2.40.0.34.6.0.11.3.38 'Severity Observation' (2019-11-21T09:31:57) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">SUBJ</span><span class="ppsign">"</span> <span class="ppattribute">inversionInd</span><span class="ppsign">="</span><span class="ppcontent">true</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 1.2.40.0.34.6.0.11.3.35 'Criticality Observation' (2019-11-21T09:04:18) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">SUBJ</span><span class="ppsign">"</span> <span class="ppattribute">inversionInd</span><span class="ppsign">="</span><span class="ppcontent">true</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 1.2.40.0.34.6.0.11.3.36 'Certainty Observation' (2019-11-21T09:11:18) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">REFR</span><span class="ppsign">"</span> <span class="ppattribute">inversionInd</span><span class="ppsign">="</span><span class="ppcontent">false</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 1.2.40.0.34.6.0.11.3.49 'Problem Status Observation' (2019-12-03T09:46:18) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">observation</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:observation<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">OBS</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>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</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;">@negationInd<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>bl</td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2">
 
<div style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51); margin: 0px 0px 4px; vertical-align: top;">SOLL standardmäßig auf false gesetzt werden.</div>
 
<div style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51); margin: 0px 0px 4px; vertical-align: top;">SOLL standardmäßig auf false gesetzt werden.</div>
 
<div style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51); margin: 0px 0px 4px; vertical-align: top;">Kann auf true gesetzt werden, um anzuzeigen, dass das dokumentierte Problem <u style="font: inherit; color: inherit;">nicht</u> beobachtet wurde.</div>
 
<div style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51); margin: 0px 0px 4px; vertical-align: top;">Kann auf true gesetzt werden, um anzuzeigen, dass das dokumentierte Problem <u style="font: inherit; color: inherit;">nicht</u> beobachtet wurde.</div>
Zeile 15: Zeile 15:
 
<b>Codierte Angabe des Gesundheitsproblems</b>:<br />@value enthält den Code des Gesundheitsproblems aus dem Value Set (ICD-10, ICPC2, ...)</li>
 
<b>Codierte Angabe des Gesundheitsproblems</b>:<br />@value enthält den Code des Gesundheitsproblems aus dem Value Set (ICD-10, ICPC2, ...)</li>
 
<li>
 
<li>
<b>Codierte Angabe ohne passenden Code</b>: <br />xsi:type='CD', nullFlavor:  OTH <br />in diesem Fall ist das Element Translation &lt;translation&gt; verpflichtend<br />originalText.reference enthält den Verweis auf die narrative Beschreibung des Problems</li>
+
<b>Codierte Angabe ohne passenden Code</b>: <br />xsi:type='CD', nullFlavor: OTH <br />in diesem Fall ist das Element Translation &lt;translation&gt; verpflichtend<br />originalText.reference enthält den Verweis auf die narrative Beschreibung des Problems</li>
 
<li>
 
<li>
<b>Uncodierte Angabe</b>: <br />xsi:type='CD', nullFlavor:  NA <br />in diesem Fall ist die Textreferenz &lt;originalText&gt; verpflichtend<br />originalText.reference enthält den Verweis auf die narrative Beschreibung des Problems</li>
+
<b>Uncodierte Angabe</b>: <br />xsi:type='CD', nullFlavor: NA <br />in diesem Fall ist die Textreferenz &lt;originalText&gt; verpflichtend<br />originalText.reference enthält den Verweis auf die narrative Beschreibung des Problems</li>
 
</ul>
 
</ul>
 
<div> </div>
 
<div> </div>
 
<ul> </ul>
 
<ul> </ul>
 
</div>Elemente in der Auswahl:<ul><li>hl7:value[not(@nullFlavor)]</li><li>hl7:value[@nullFlavor='OTH']</li><li>hl7:value[@nullFlavor='NA']</li></ul></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: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;">hl7:value<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></strong></span></td><td>Codierte Angabe des Gesundheitsproblems<br />
 
</div>Elemente in der Auswahl:<ul><li>hl7:value[not(@nullFlavor)]</li><li>hl7:value[@nullFlavor='OTH']</li><li>hl7:value[@nullFlavor='NA']</li></ul></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: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;">hl7:value<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></strong></span></td><td>Codierte Angabe des Gesundheitsproblems<br />
</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo  <i> [not(@nullFlavor)]</i></td><td></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: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;">@xsi:type<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td></td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">CD</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">Mögliche Codesysteme:<br />
+
<br /> Codesysteme bitte in der aktuellen Version verwenden. Z.B.:<br />
 
<div>
 
<div>
 
<ul>
 
<ul>
<li>1.2.40.0.34.5.184 - ICD-10 BMASGK 2020 (oder eine höhere Version)  </li>
+
<li>1.2.40.0.34.5.184 - ICD-10 BMASGK  </li>
<li>1.2.40.0.34.5.175 - ICPC2 (International Classification of Primary Care) 2017 (oder eine höhere Version) </li>
+
<li>1.2.40.0.34.5.175 - ICPC2 (International Classification of Primary Care)</li>
 
<li>2.16.840.1.113883.6.254 - ICF (WHO International Classification of Function)</li>
 
<li>2.16.840.1.113883.6.254 - ICF (WHO International Classification of Function)</li>
 
<li>2.16.840.1.113883.6.96 - SNOMED CT</li>
 
<li>2.16.840.1.113883.6.96 - SNOMED CT</li>
 +
<li>etc.</li>
 
</ul>
 
</ul>
 
</div>
 
</div>
</td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td colspan="2"> von 1.2.40.0.34.6.0.11.9.2 <i>Original Text Reference</i> (DYNAMIC)</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:Treeblank.png|16px]]</td><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;">hl7:originalText<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>ED</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>Textinhalt, der codiert wurde.<br /></td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><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;">hl7:reference<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>TEL</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>Die Referenz auf den entsprechenden Text im narrativen Teil muss durch Bezugnahme auf den Inhalt[@ID] angegeben werden: reference[@value='#xxx'].<br />Die Referenz ist mit einem <i>content</i>-Element mit <i>ID</i>-Attribut anzugeben, dieses Element DARF NUR den Textinhalt des codierten Inhalts umschließen und KEINE zusätzlichen Markup oder Strukturelemente.</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><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;">@value<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td></td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2"> error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">starts-with(@value,'#')</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2"><span class="pptext">The @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content'-element.</span></td><td style="background-color: white;"> </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:Treeblank.png|16px]]</td><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;">hl7:qualifier<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CR</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>
+
</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo  <i> [not(@nullFlavor)]</i></td><td></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: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;">@xsi:type<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td></td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">CD</td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td colspan="2"> von 1.2.40.0.34.6.0.11.9.2 <i>Original Text Reference</i> (DYNAMIC)<br />
 +
<div>Eingegebener Freitext, der die Grundlage der im Entry angegebenen Information ist. <br />Das Element verweist auf die Stelle im Textbereich (section.text), in dem das Problem beschrieben ist (ohne zusätzliche Informationen, wie Datum, Beschreibung, etc).</div>
 +
<div>Grundsätzlich sind die Vorgaben für „Codierungs-Elemente“ zu befolgen.</div>
 +
</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:Treeblank.png|16px]]</td><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;">hl7:originalText<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>ED</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>Textinhalt, der codiert wurde.<br /></td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><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;">hl7:reference<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>TEL</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>Die Referenz auf den entsprechenden Text im narrativen Teil muss durch Bezugnahme auf den Inhalt[@ID] angegeben werden: reference[@value='#xxx'].<br />Die Referenz ist mit einem <i>content</i>-Element mit <i>ID</i>-Attribut anzugeben, dieses Element DARF NUR den Textinhalt des codierten Inhalts umschließen und KEINE zusätzlichen Markup oder Strukturelemente.</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><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;">@value<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td></td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2"> error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">starts-with(@value,'#')</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2"><span class="pptext">The @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content'-element.</span></td><td style="background-color: white;"> </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:Treeblank.png|16px]]</td><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;">hl7:qualifier<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CR</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>
 
<div>Qualifier zur genaueren Beschreibung des Problems. </div>
 
<div>Qualifier zur genaueren Beschreibung des Problems. </div>
 
<div>z.B. zur Angabe der Art der Diagnose.</div>
 
<div>z.B. zur Angabe der Art der Diagnose.</div>
Zeile 45: Zeile 49:
 
<div>z. B. für Übersetzungen in alternative Codesysteme oder wenn kein geeigneter Code im vorgegebene VS vorhanden ist.</div>
 
<div>z. B. für Übersetzungen in alternative Codesysteme oder wenn kein geeigneter Code im vorgegebene VS vorhanden ist.</div>
 
</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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: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;">hl7:value<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></strong></span></td><td>Uncodierte Angabe<br />
 
</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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: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;">hl7:value<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></strong></span></td><td>Uncodierte Angabe<br />
</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo  <i> [@nullFlavor='NA']</i></td><td></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: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;">@xsi:type<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td></td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">CD</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: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;">@nullFlavor<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">NA</td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td colspan="2"> von 1.2.40.0.34.6.0.11.9.2 <i>Original Text Reference</i> (DYNAMIC)</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:Treeblank.png|16px]]</td><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;">hl7:originalText<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>ED</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>Textinhalt, der codiert wurde.<br /></td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><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;">hl7:reference<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>TEL</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>Die Referenz auf den entsprechenden Text im narrativen Teil muss durch Bezugnahme auf den Inhalt[@ID] angegeben werden: reference[@value='#xxx'].<br />Die Referenz ist mit einem <i>content</i>-Element mit <i>ID</i>-Attribut anzugeben, dieses Element DARF NUR den Textinhalt des codierten Inhalts umschließen und KEINE zusätzlichen Markup oder Strukturelemente.</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><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;">@value<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td></td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2"> error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">starts-with(@value,'#')</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2"><span class="pptext">The @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content'-element.</span></td><td style="background-color: white;"> </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:target&#8203;Site&#8203;Code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CD</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Anatomische Lage des Problems<br />Beinhaltet 1.2.40.0.34.6.0.11.9.42 <i>Laterality Qualifier</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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:performer<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.9.17 <i>Performer Body</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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:author<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Dieses Author-Element KANN verwendet werden, um anzugeben, wer das Problem dokumentiert hat. Wenn nicht angegeben, gilt das jeweils "darüberlegende" Author-Element (Section, Document)<br />
+
</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo  <i> [@nullFlavor='NA']</i></td><td></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: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;">@xsi:type<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td></td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">CD</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: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;">@nullFlavor<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">NA</td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td colspan="2"> von 1.2.40.0.34.6.0.11.9.2 <i>Original Text Reference</i> (DYNAMIC)<br />
 +
<div>Eingegebener Freitext, der die Grundlage der im Entry angegebenen Information ist. <br />Das Element verweist auf die Stelle im Textbereich (section.text), in dem das Problem beschrieben ist (ohne zusätzliche Informationen, wie Datum, Beschreibung, etc).</div>
 +
<div>Grundsätzlich sind die Vorgaben für „Codierungs-Elemente“ zu befolgen.</div>
 +
</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:Treeblank.png|16px]]</td><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;">hl7:originalText<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>ED</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>Textinhalt, der codiert wurde.<br /></td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><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;">hl7:reference<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>TEL</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>Die Referenz auf den entsprechenden Text im narrativen Teil muss durch Bezugnahme auf den Inhalt[@ID] angegeben werden: reference[@value='#xxx'].<br />Die Referenz ist mit einem <i>content</i>-Element mit <i>ID</i>-Attribut anzugeben, dieses Element DARF NUR den Textinhalt des codierten Inhalts umschließen und KEINE zusätzlichen Markup oder Strukturelemente.</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><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;">@value<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td></td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2"> error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">starts-with(@value,'#')</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2"><span class="pptext">The @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content'-element.</span></td><td style="background-color: white;"> </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:target&#8203;Site&#8203;Code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CD</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Anatomische Lage des Problems<br />Beinhaltet 1.2.40.0.34.6.0.11.9.42 <i>Laterality Qualifier</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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:performer<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.9.17 <i>Performer Body</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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:author<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Dieses Author-Element KANN verwendet werden, um anzugeben, wer das Problem dokumentiert hat. Wenn nicht angegeben, gilt das jeweils "darüberlegende" Author-Element (Section, Document)<br />
 
<br />Beinhaltet 1.2.40.0.34.6.0.11.9.36 <i>Author Body</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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:informant<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.9.3 <i>Informant Body</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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:participant<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.9.13 <i>Participant Body</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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:entryRelationship<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.3.11 <i>Comment Entry</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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;">@typeCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</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;">@context&#8203;Conduction&#8203;Ind<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">true</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:entryRelationship<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>Dieses EntryRelationship dient zur Darstellung des Schweregrads des Gesundheitsproblems.<br />Beinhaltet 1.2.40.0.34.6.0.11.3.38 <i>Severity Observation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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;">@typeCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">SUBJ</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;">@inversionInd<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>bl</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">true</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;">@context&#8203;Conduction&#8203;Ind<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">true</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:entryRelationship<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>Dieses EntryRelationship dient zur Darstellung der Kritizität des Gesundheitsproblems.<br />Beinhaltet 1.2.40.0.34.6.0.11.3.35 <i>Criticality Observation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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;">@typeCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">SUBJ</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;">@inversionInd<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>bl</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">true</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;">@context&#8203;Conduction&#8203;Ind<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">true</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:entryRelationship<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>Dieses EntryRelationship dient zur Darstellung der Gewissheit, mit der das Gesundheitsproblem besteht<br />Beinhaltet 1.2.40.0.34.6.0.11.3.36 <i>Certainty Observation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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;">@typeCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">SUBJ</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;">@inversionInd<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>bl</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">true</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;">@context&#8203;Conduction&#8203;Ind<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">true</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:entryRelationship<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>Klinischer Status des Gesundheitsproblems<br />Beinhaltet 1.2.40.0.34.6.0.11.3.49 <i>Problem Status Observation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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;">@typeCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">REFR</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;">@inversionInd<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>bl</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">false</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;">@context&#8203;Conduction&#8203;Ind<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">true</td></tr></table></td></tr></table>
 
<br />Beinhaltet 1.2.40.0.34.6.0.11.9.36 <i>Author Body</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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:informant<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.9.3 <i>Informant Body</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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:participant<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.9.13 <i>Participant Body</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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:entryRelationship<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.3.11 <i>Comment Entry</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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;">@typeCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</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;">@context&#8203;Conduction&#8203;Ind<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">true</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:entryRelationship<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>Dieses EntryRelationship dient zur Darstellung des Schweregrads des Gesundheitsproblems.<br />Beinhaltet 1.2.40.0.34.6.0.11.3.38 <i>Severity Observation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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;">@typeCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">SUBJ</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;">@inversionInd<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>bl</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">true</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;">@context&#8203;Conduction&#8203;Ind<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">true</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:entryRelationship<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>Dieses EntryRelationship dient zur Darstellung der Kritizität des Gesundheitsproblems.<br />Beinhaltet 1.2.40.0.34.6.0.11.3.35 <i>Criticality Observation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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;">@typeCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">SUBJ</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;">@inversionInd<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>bl</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">true</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;">@context&#8203;Conduction&#8203;Ind<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">true</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:entryRelationship<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>Dieses EntryRelationship dient zur Darstellung der Gewissheit, mit der das Gesundheitsproblem besteht<br />Beinhaltet 1.2.40.0.34.6.0.11.3.36 <i>Certainty Observation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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;">@typeCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">SUBJ</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;">@inversionInd<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>bl</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">true</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;">@context&#8203;Conduction&#8203;Ind<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">true</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:entryRelationship<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>Klinischer Status des Gesundheitsproblems<br />Beinhaltet 1.2.40.0.34.6.0.11.3.49 <i>Problem Status Observation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...lem)</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;">@typeCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">REFR</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;">@inversionInd<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>bl</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">false</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;">@context&#8203;Conduction&#8203;Ind<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">true</td></tr></table></td></tr></table>
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Id1.2.40.0.34.6.0.11.3.31
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  • Kblank.png elgagab_entry_KonsultationsgrundProblem vom 2021‑02‑19 10:46:53
  • Kblank.png elgagab_entry_KonsultationsgrundProblem vom 2020‑11‑05 15:01:55
  • Kblank.png elgagab_entry_KonsultationsgrundProblem vom 2018‑11‑20 09:56:38
StatusKyellow.png EntwurfVersions-Label1.1.3
Nameelgagab_entry_KonsultationsgrundProblemBezeichnungKonsultationsgrund Problem Entry
Beschreibung
Mit dieser Observation wird ein bekanntes relevantes Gesundheitsproblem des Patienten codiert dargestellt.
Die Zeitspanne, in der ein Gesundheitsproblem besteht oder bestanden hat, wird hier angegeben. 
KontextElternknoten des Template-Element mit Id 1.2.40.0.34.6.0.11.3.31
KlassifikationCDA Entry Level Template
Template-Typ nicht spezifiziert
Offen/GeschlossenGeschlossen (nur definierte Elemente sind erlaubt)
Benutzt
Benutzt 12 Templates
Benutzt als NameVersion
1.2.40.0.34.6.0.11.9.1InklusionKgreen.png Narrative Text Reference (1.0.1+20210512)DYNAMIC
1.2.40.0.34.6.0.11.9.2InklusionKgreen.png Original Text Reference (1.0.0+20210219)DYNAMIC
1.2.40.0.34.6.0.11.9.42ContainmentKgreen.png Laterality Qualifier (1.0.0+20210219)DYNAMIC
1.2.40.0.34.6.0.11.9.17ContainmentKgreen.png Performer Body (1.0.0+20210219)DYNAMIC
1.2.40.0.34.6.0.11.9.36ContainmentKgreen.png Author Body (1.0.1+20230717)DYNAMIC
1.2.40.0.34.6.0.11.9.3ContainmentKgreen.png Informant Body (1.0.1+20211213)DYNAMIC
1.2.40.0.34.6.0.11.9.13ContainmentKgreen.png Participant Body (1.0.1+20210628)DYNAMIC
1.2.40.0.34.6.0.11.3.11ContainmentKgreen.png Comment Entry (1.0.0+20210219)DYNAMIC
1.2.40.0.34.6.0.11.3.38ContainmentKgreen.png Severity Observation (1.0.0+20210219)DYNAMIC
1.2.40.0.34.6.0.11.3.35ContainmentKgreen.png Criticality Observation (1.0.1+20210628)DYNAMIC
1.2.40.0.34.6.0.11.3.36ContainmentKgreen.png Certainty Observation (1.0.0+20210219)DYNAMIC
1.2.40.0.34.6.0.11.3.49ContainmentKgreen.png Problem Status Observation (1.0.0+20210219)DYNAMIC
BeziehungVersion: Template 1.2.40.0.34.6.0.11.3.31 Konsultationsgrund Problem Entry (2022‑06‑02 15:20:46)
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at-cda-bbr-

Version: Template 1.2.40.0.34.6.0.11.3.31 Konsultationsgrund Problem Entry (2021‑08‑10 08:43:36)
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at-cda-bbr-

Version: Template 1.2.40.0.34.6.0.11.3.31 Konsultationsgrund Problem Entry (2021‑02‑19 10:46:53)
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at-cda-bbr-

Version: Template 1.2.40.0.34.6.0.11.3.31 Konsultationsgrund Problem Entry (2020‑11‑05 15:01:55)
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at-cda-bbr-

Version: Template 1.2.40.0.34.6.0.11.3.31 Konsultationsgrund Problem Entry (2018‑11‑20 09:56:38)
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at-cda-bbr-

Adaptation: Template 1.2.40.0.34.6.0.11.3.6 Problem Entry (DYNAMIC)
ref
at-cda-bbr-
Beispiel
Strukturbeispiel
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="1.2.40.0.34.6.0.11.3.31"/>  <templateId root="2.16.840.1.113883.10.20.1.28"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>  <id/>  <code code="55607006" codeSystem="2.16.840.1.113883.6.96" displayName="Problem (finding)"/>  <!-- include template 1.2.40.0.34.6.0.11.9.1 'Narrative Text Reference' (dynamic) 1..1 M -->
  <statusCode code="completed"/>  <effectiveTime>
    <low value="2019"/>  </effectiveTime>
  <!-- choice: 1..1
element hl7:value[not(@nullFlavor)]
element hl7:value[@nullFlavor='OTH']
element hl7:value[@nullFlavor='NA']
-->
  <targetSiteCode>
    <!-- template 1.2.40.0.34.6.0.11.9.42 'Laterality Qualifier' (2020-02-20T09:00:36) -->
  </targetSiteCode>
  <performer>
    <!-- template 1.2.40.0.34.6.0.11.9.17 'Performer Body' (2019-01-17T12:44:16) -->
  </performer>
  <author>
    <!-- template 1.2.40.0.34.6.0.11.9.36 'Author Body' (2019-11-20T12:13:04) -->
  </author>
  <informant>
    <!-- template 1.2.40.0.34.6.0.11.9.3 'Informant Body' (2019-02-07T13:29:32) -->
  </informant>
  <participant>
    <!-- template 1.2.40.0.34.6.0.11.9.13 'Participant Body' (2019-04-03T12:08:16) -->
  </participant>
  <entryRelationship typeCode="COMP" contextConductionInd="true">
    <!-- template 1.2.40.0.34.6.0.11.3.11 'Comment Entry' (2019-02-07T13:10:44) -->
  </entryRelationship>
  <entryRelationship typeCode="SUBJ" inversionInd="true" contextConductionInd="true">
    <!-- template 1.2.40.0.34.6.0.11.3.38 'Severity Observation' (2019-11-21T09:31:57) -->
  </entryRelationship>
  <entryRelationship typeCode="SUBJ" inversionInd="true" contextConductionInd="true">
    <!-- template 1.2.40.0.34.6.0.11.3.35 'Criticality Observation' (2019-11-21T09:04:18) -->
  </entryRelationship>
  <entryRelationship typeCode="SUBJ" inversionInd="true" contextConductionInd="true">
    <!-- template 1.2.40.0.34.6.0.11.3.36 'Certainty Observation' (2019-11-21T09:11:18) -->
  </entryRelationship>
  <entryRelationship typeCode="REFR" inversionInd="false" contextConductionInd="true">
    <!-- template 1.2.40.0.34.6.0.11.3.49 'Problem Status Observation' (2019-12-03T09:46:18) -->
  </entryRelationship>
</observation>
ItemDTKardKonfBeschreibungLabel
hl7:observation
(elg...lem)
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl1 … 1R
SOLL standardmäßig auf false gesetzt werden.
Kann auf true gesetzt werden, um anzuzeigen, dass das dokumentierte Problem nicht beobachtet wurde.
Treetree.pnghl7:templateId
II1 … 1M(elg...lem)
Treeblank.pngTreetree.png@root
uid1 … 1F1.2.40.0.34.6.0.11.3.31
Treetree.pnghl7:templateId
II1 … 1MHL7 CCD Problem observation(elg...lem)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.20.1.28
Treetree.pnghl7:templateId
II1 … 1MIHE Problem Entry(elg...lem)
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.5
Treetree.pnghl7:id
1 … *MSysteminterne ID des entsprechenden Problems - zur Referenzierung oder Aggregierung.


Auch wenn nur ein Problem-Entry angegeben ist, soll sich die ID von der ID des Problem/Bedenken-Entry unterscheiden.

(elg...lem)
Treetree.pnghl7:code
CE1 … 1MDas "code"-Element enthält die Art des beschriebenen Gesundheitsproblems, die Verwendung von 'Problem' ist empfohlen.
(elg...lem)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 1.2.40.0.34.10.205 ELGA_TypeOfProblem_VS (DYNAMIC)
Eingefügt1 … 1M von 1.2.40.0.34.6.0.11.9.1 Narrative Text Reference (DYNAMIC)
Treetree.pnghl7:text
ED1 … 1M(elg...lem)
Treeblank.pngTreetree.pnghl7:reference
TEL1 … 1MDie Referenz auf den entsprechenden Text im menschenlesbaren Teil muss durch Bezugnahme auf den Inhalt[@ID] angegeben werden: reference[@value='#xxx'].
Die Referenz ist mit einem ID-Attribut anzugeben, dieses Element DARF NUR den Textinhalt des codierten Inhalts mit Zusatzinformationen umschließen.

Alternativ kann @value auch mit dem url-scheme "http" oder "https" beginnen.


(elg...lem)
Treeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
 Schematron assertrole error 
 teststarts-with(@value,'#') or starts-with(@value,'http') 
 MeldungThe @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content'-element, or begin with the 'http' or 'https' url-scheme. 
Treetree.pnghl7:statusCode
CS1 … 1MFixer Wert: completed(elg...lem)
Treeblank.pngTreetree.png@code
CONF1 … 1Fcompleted
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1M
Zeitintervall, in dem das Gesundheitsproblems existent war/ist.
Grundsätzlich sind die Vorgaben für „Zeit-Elemente“ zu befolgen.
(elg...lem)
Treeblank.pngTreetree.pnghl7:low
TS.AT.VAR1 … 1RZeitpunkt des Beginns des Gesundheitsproblems (für den Patienten).
Ist dieser Zeitpunkt nicht bekannt, ist effectiveTime.low mit nullFlavor "UNK" anzugeben
(elg...lem)
Treeblank.pngTreetree.pnghl7:high
TS.AT.VAR0 … 1CZeitpunkt, an dem das Gesundheitsproblem gelöst wurde oder seitdem das Gesundheitsproblem nicht mehr besteht. 
Ist dieser Zeitpunkt nicht bekannt, ist effectiveTime.high mit nullFlavor "UNK" anzugeben
(elg...lem)
Auswahl1 … 1
Angabe des Gesundheitsproblems:
  • Codierte Angabe des Gesundheitsproblems:
    @value enthält den Code des Gesundheitsproblems aus dem Value Set (ICD-10, ICPC2, ...)
  • Codierte Angabe ohne passenden Code
    xsi:type='CD', nullFlavor: OTH 
    in diesem Fall ist das Element Translation <translation> verpflichtend
    originalText.reference enthält den Verweis auf die narrative Beschreibung des Problems
  • Uncodierte Angabe
    xsi:type='CD', nullFlavor: NA 
    in diesem Fall ist die Textreferenz <originalText> verpflichtend
    originalText.reference enthält den Verweis auf die narrative Beschreibung des Problems
Elemente in der Auswahl:
  • hl7:value[not(@nullFlavor)]
  • hl7:value[@nullFlavor='OTH']
  • hl7:value[@nullFlavor='NA']
Treeblank.pngTreetree.pnghl7:value
0 … 1Codierte Angabe des Gesundheitsproblems


Codesysteme bitte in der aktuellen Version verwenden. Z.B.:

  • 1.2.40.0.34.5.184 - ICD-10 BMASGK  
  • 1.2.40.0.34.5.175 - ICPC2 (International Classification of Primary Care)
  • 2.16.840.1.113883.6.254 - ICF (WHO International Classification of Function)
  • 2.16.840.1.113883.6.96 - SNOMED CT
  • etc.
(elg...lem)
wo [not(@nullFlavor)]
Treeblank.pngTreeblank.pngTreetree.png@xsi:type
1 … 1FCD
Eingefügt0 … 1R von 1.2.40.0.34.6.0.11.9.2 Original Text Reference (DYNAMIC)
Eingegebener Freitext, der die Grundlage der im Entry angegebenen Information ist. 
Das Element verweist auf die Stelle im Textbereich (section.text), in dem das Problem beschrieben ist (ohne zusätzliche Informationen, wie Datum, Beschreibung, etc).
Grundsätzlich sind die Vorgaben für „Codierungs-Elemente“ zu befolgen.
Treeblank.pngTreeblank.pngTreetree.pnghl7:originalText
ED0 … 1RTextinhalt, der codiert wurde.
(elg...lem)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:reference
TEL1 … 1MDie Referenz auf den entsprechenden Text im narrativen Teil muss durch Bezugnahme auf den Inhalt[@ID] angegeben werden: reference[@value='#xxx'].
Die Referenz ist mit einem content-Element mit ID-Attribut anzugeben, dieses Element DARF NUR den Textinhalt des codierten Inhalts umschließen und KEINE zusätzlichen Markup oder Strukturelemente.
(elg...lem)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
 Schematron assertrole error 
 teststarts-with(@value,'#') 
 MeldungThe @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content'-element. 
Treeblank.pngTreeblank.pngTreetree.pnghl7:qualifier
CR0 … *
Qualifier zur genaueren Beschreibung des Problems. 
z.B. zur Angabe der Art der Diagnose.
(elg...lem)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
CV1 … 1M(elg...lem)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1F106229004
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F2.16.840.1.113883.6.96
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:value
CD1 … 1M(elg...lem)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 1.2.40.0.34.6.0.10.23 elgagab_Art_der_Diagnose_VS (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.pnghl7:translation
CD0 … *
Dieses Feld wird verwendet, wenn Codes aus einem abweichenden Value Set angegeben werden. 
z. B. für Übersetzungen in alternative Codesysteme oder wenn kein geeigneter Code im vorgegebene VS vorhanden ist.
(elg...lem)
Treeblank.pngTreetree.pnghl7:value
0 … 1Codierte Angabe ohne passenden Code
(elg...lem)
wo [@nullFlavor='OTH']
Treeblank.pngTreeblank.pngTreetree.png@xsi:type
1 … 1FCD
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs1 … 1FOTH
Eingefügt1 … 1M von 1.2.40.0.34.6.0.11.9.2 Original Text Reference (DYNAMIC)
Eingegebener Freitext, der die Grundlage der im Entry angegebenen Information ist. 
Das Element verweist auf die Stelle im Textbereich (section.text), in dem das Problem beschrieben ist (ohne zusätzliche Informationen, wie Datum, Beschreibung, etc).
Grundsätzlich sind die Vorgaben für „Codierungs-Elemente“ zu befolgen.
Treeblank.pngTreeblank.pngTreetree.pnghl7:originalText
ED1 … 1MTextinhalt, der codiert wurde.
(elg...lem)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:reference
TEL1 … 1MDie Referenz auf den entsprechenden Text im narrativen Teil muss durch Bezugnahme auf den Inhalt[@ID] angegeben werden: reference[@value='#xxx'].
Die Referenz ist mit einem content-Element mit ID-Attribut anzugeben, dieses Element DARF NUR den Textinhalt des codierten Inhalts umschließen und KEINE zusätzlichen Markup oder Strukturelemente.
(elg...lem)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
 Schematron assertrole error 
 teststarts-with(@value,'#') 
 MeldungThe @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content'-element. 
Treeblank.pngTreeblank.pngTreetree.pnghl7:translation
CD1 … *M
Dieses Feld wird verwendet, wenn Codes aus einem abweichenden Value Set angegeben werden. 
z. B. für Übersetzungen in alternative Codesysteme oder wenn kein geeigneter Code im vorgegebene VS vorhanden ist.
(elg...lem)
Treeblank.pngTreetree.pnghl7:value
0 … 1Uncodierte Angabe
(elg...lem)
wo [@nullFlavor='NA']
Treeblank.pngTreeblank.pngTreetree.png@xsi:type
1 … 1FCD
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs1 … 1FNA
Eingefügt1 … 1M von 1.2.40.0.34.6.0.11.9.2 Original Text Reference (DYNAMIC)
Eingegebener Freitext, der die Grundlage der im Entry angegebenen Information ist. 
Das Element verweist auf die Stelle im Textbereich (section.text), in dem das Problem beschrieben ist (ohne zusätzliche Informationen, wie Datum, Beschreibung, etc).
Grundsätzlich sind die Vorgaben für „Codierungs-Elemente“ zu befolgen.
Treeblank.pngTreeblank.pngTreetree.pnghl7:originalText
ED1 … 1MTextinhalt, der codiert wurde.
(elg...lem)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:reference
TEL1 … 1MDie Referenz auf den entsprechenden Text im narrativen Teil muss durch Bezugnahme auf den Inhalt[@ID] angegeben werden: reference[@value='#xxx'].
Die Referenz ist mit einem content-Element mit ID-Attribut anzugeben, dieses Element DARF NUR den Textinhalt des codierten Inhalts umschließen und KEINE zusätzlichen Markup oder Strukturelemente.
(elg...lem)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
 Schematron assertrole error 
 teststarts-with(@value,'#') 
 MeldungThe @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content'-element. 
Treetree.pnghl7:target​Site​Code
CD0 … *Anatomische Lage des Problems
Beinhaltet 1.2.40.0.34.6.0.11.9.42 Laterality Qualifier (DYNAMIC)
(elg...lem)
Treetree.pnghl7:performer
0 … *RBeinhaltet 1.2.40.0.34.6.0.11.9.17 Performer Body (DYNAMIC)(elg...lem)
Treetree.pnghl7:author
0 … *RDieses Author-Element KANN verwendet werden, um anzugeben, wer das Problem dokumentiert hat. Wenn nicht angegeben, gilt das jeweils "darüberlegende" Author-Element (Section, Document)

Beinhaltet 1.2.40.0.34.6.0.11.9.36 Author Body (DYNAMIC)
(elg...lem)
Treetree.pnghl7:informant
0 … *RBeinhaltet 1.2.40.0.34.6.0.11.9.3 Informant Body (DYNAMIC)(elg...lem)
Treetree.pnghl7:participant
0 … *RBeinhaltet 1.2.40.0.34.6.0.11.9.13 Participant Body (DYNAMIC)(elg...lem)
Treetree.pnghl7:entryRelationship
0 … *RBeinhaltet 1.2.40.0.34.6.0.11.3.11 Comment Entry (DYNAMIC)(elg...lem)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
cs0 … 1Ftrue
Treetree.pnghl7:entryRelationship
0 … 1RDieses EntryRelationship dient zur Darstellung des Schweregrads des Gesundheitsproblems.
Beinhaltet 1.2.40.0.34.6.0.11.3.38 Severity Observation (DYNAMIC)
(elg...lem)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSUBJ
Treeblank.pngTreetree.png@inversionInd
bl1 … 1Ftrue
Treeblank.pngTreetree.png@context​Conduction​Ind
cs0 … 1Ftrue
Treetree.pnghl7:entryRelationship
0 … 1RDieses EntryRelationship dient zur Darstellung der Kritizität des Gesundheitsproblems.
Beinhaltet 1.2.40.0.34.6.0.11.3.35 Criticality Observation (DYNAMIC)
(elg...lem)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSUBJ
Treeblank.pngTreetree.png@inversionInd
bl1 … 1Ftrue
Treeblank.pngTreetree.png@context​Conduction​Ind
cs0 … 1Ftrue
Treetree.pnghl7:entryRelationship
0 … 1RDieses EntryRelationship dient zur Darstellung der Gewissheit, mit der das Gesundheitsproblem besteht
Beinhaltet 1.2.40.0.34.6.0.11.3.36 Certainty Observation (DYNAMIC)
(elg...lem)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSUBJ
Treeblank.pngTreetree.png@inversionInd
bl1 … 1Ftrue
Treeblank.pngTreetree.png@context​Conduction​Ind
cs0 … 1Ftrue
Treetree.pnghl7:entryRelationship
0 … 1RKlinischer Status des Gesundheitsproblems
Beinhaltet 1.2.40.0.34.6.0.11.3.49 Problem Status Observation (DYNAMIC)
(elg...lem)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFR
Treeblank.pngTreetree.png@inversionInd
bl1 … 1Ffalse
Treeblank.pngTreetree.png@context​Conduction​Ind
cs0 … 1Ftrue