1.2.40.0.34.6.0.11.3.16/static-2019-05-07T134402: Unterschied zwischen den Versionen

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<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.2.40.0.34.6.0.11.3.16</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2019‑05‑07 13:44:02</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;">2019</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">atcdabbr_entry_LaboratoryObservation</td><th style="width: 20em; text-align: left;">Anzeigename</th><td style="text-align: left;">Laboratory Observation</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 1.2.40.0.34.6.0.11.3.16</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</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Offen/Geschlossen</th><td style="text-align: left;" colspan="3">Offen (auch andere als die definierten 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 class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Benutzt 2 Templates</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" 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;">1.2.40.0.34.11.4.3.2</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Befundtext (Anmerkungen und Kommentare)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.11.4.3.3</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Laboratory Performer 2</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">Spezialisierung: Template 1.3.6.1.4.1.19376.1.3.1.6 <i>Laborergebnisse (Laboratory Observation) </i> (2015‑03‑26) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">elgabbr-</div></span><br />Version: Template 1.3.6.1.4.1.19376.1.3.1.6 <i>Laborergebnisse (Laboratory Observation) </i> (2015‑03‑26) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">elgabbr-</div></span></td></tr><tr class="explabel " style="vertical-align: top;"><td style="width: 20em; text-align: left;">Beispiel</td><td colspan="3" class="explabelgreen"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Strukturbeispiel Laborergebnis (Laboratory Observation)</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">ClinicalDocument</span><span class="ppsign">&gt;</span><br /><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="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- TemplateId für Laboratory Observation --&gt;<br /></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">1.3.6.1.4.1.19376.1.3.1.6</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Testidentifikation --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">id</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">OBS-1-4</span><span class="ppsign">"</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.2.16.1.99.3.1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Analyse/Testcode --&gt;<br /></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">26464-8</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">LOINC</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Leukozyten</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Verweis auf den narrativen Text --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#OBS-1-4</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">text</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Status des Laborergebnisses --&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;">    <span style="color:green">&lt;!-- medizinisch relevanter Zeitpunkt --&gt;<br /></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">20131201073406+0100</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">high</span> <span class="ppattribute">nullFlavor</span><span class="ppsign">="</span><span class="ppcontent">UNK</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;!-- Ergebnis der Analyse / des Tests --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">value</span> <span class="ppattribute">unit</span><span class="ppsign">="</span><span class="ppcontent">g/dL</span><span class="ppsign">"</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">16.0</span><span class="ppsign">"</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">PQ</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Bewertung des Ergebnisses --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">interpretationCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">N</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">HL7:ObservationInterpretation</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.5.83</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">normal</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Validator --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">participant</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">AUTHEN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext"> : </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;">    <span style="color:green">&lt;!-- Durchführende Instanz / externes Labor --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">performer</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">PRF</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext"> : </span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">performer</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 class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">ClinicalDocument</span><span class="ppsign">&gt;</span></span></tt></td></tr></table></td></tr><tr class="explabel " style="vertical-align: top;"><td style="width: 20em; text-align: left;">Beispiel</td><td colspan="3" class="explabelgreen"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Strukturbeispiel für ein Laborergebnis mit Cut-off-Wert (Datentyp IVL_PQ)</span></td></tr><tr><td><tt><span style="display: block;"><span style="color:green">&lt;!--So kann ein Wert von &gt; 500 mg/dl dargestellt und bewertet werden:--&gt;<br /></span></span><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">ClinicalDocument</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">IVL_PQ</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">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">500</span><span class="ppsign">"</span> <span class="ppattribute">unit</span><span class="ppsign">="</span><span class="ppcontent">mg/dl</span><span class="ppsign">"</span> <span class="ppattribute">inclusive</span><span class="ppsign">="</span><span class="ppcontent">false</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">high</span> <span class="ppattribute">nullFlavor</span><span class="ppsign">="</span><span class="ppcontent">PINF</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">value</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">interpretationCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent"> &gt;</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">High off scale</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.5.83 </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">ClinicalDocument</span><span class="ppsign">&gt;</span></span></tt></td></tr></table></td></tr><tr class="explabel " style="vertical-align: top;"><td style="width: 20em; text-align: left;">Beispiel</td><td colspan="3" class="explabelgreen"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Strukturbeispiel für ein in Arbeit befindliches Laborergebnis („Wert folgt“)</span></td></tr><tr><td><tt><span style="display: block;"><span style="color:green">&lt;!--Angabe von Parametern mit ausständigem Ergebnis:--&gt;<br /></span></span><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">ClinicalDocument</span><span class="ppsign">&gt;</span><br /><span style="display: block;">  <span style="color:green">&lt;!--Angabe von Parametern mit ausständigem Ergebnis:--&gt;<br /></span></span><span style="display: block;">  <span style="color:green">&lt;!--Laboratory Observation, Ergebnis noch nicht verfügbar (Wert folgt)--&gt;<br /></span></span><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="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.3.1.6</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="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">OBS-2-6</span><span class="ppsign">"</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.2.16.1.99.3.1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">10704-5</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">LOINC</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Wurmeier Stuhl</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">text</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#OBS-2-6</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">text</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Status des Laborergebnisses --&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">active</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="ppattribute">nullFlavor</span><span class="ppsign">="</span><span class="ppcontent">UNK</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">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">ST</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">Wert folgt</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">value</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Bewertung des Ergebnisses wird nicht angegeben [NP] --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">ClinicalDocument</span><span class="ppsign">&gt;</span></span></tt></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" 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 class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:observation<br /></strong></tt></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="">(atc...ion)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></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><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@moodCode<br /></strong></tt></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; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(atc...ion)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@root<br /></strong></tt></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.40.0.34.6.0.11.3.16</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(atc...ion)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@root<br /></strong></tt></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.3.6.1.4.1.19376.1.3.1.6</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Identifikation des Tests nach einer internen Codierung. Es gelten die Vorgaben des entsprechenden Kapitels des „Allgemeinen Implementierungsleitfadens“.<br /></td><td style="background-color: #FFEEEE;"><span title="">(atc...ion)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:code<br /></strong></tt></td></tr></table></td><td><strong>CE</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Codierung der Analyse / des Tests. <br /></td><td style="background-color: #FFEEEE;"><span title="">(atc...ion)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 1.2.40.0.34.10.44 <i>ELGA_Laborparameter </i>(DYNAMIC)</td></tr></table></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">[[File:Kred.png|14px]] 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">not(@nullFlavor) or not(@nullFlavor='OTH') or hl7:translation</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">Wenn code/@nullFlavor=OTH dann MUSS entweder code/translation anwesend sein.</span></td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:text<br /></strong></tt></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></strong></span></td><td><div>Der Text zum Laborergebnis wird verwendet, um einen Verweis zum narrativen Text herzustellen, Verwendung siehe 6.2.9.2 </div></td><td style="background-color: #FFEEEE;"><span title="">(atc...ion)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:statusCode<br /></strong></tt></td></tr></table></td><td><strong>CS</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><b>Statuscode</b>.<br />
+
<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.2.40.0.34.6.0.11.3.16 <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;">2019‑05‑07 13:44:02</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;">2019</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">atcdabbr_entry_LaboratoryObservation</td><th style="width: 20em; text-align: left;">Anzeigename</th><td style="text-align: left;">Laboratory Observation</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 1.2.40.0.34.6.0.11.3.16</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</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Offen/Geschlossen</th><td style="text-align: left;" colspan="3">Offen (auch andere als die definierten 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 class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Benutzt 2 Templates</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" 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;">1.2.40.0.34.11.4.3.2</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Befundtext (Anmerkungen und Kommentare)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.11.4.3.3</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Laboratory Performer 2</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">Spezialisierung: Template 1.3.6.1.4.1.19376.1.3.1.6 <i>Laborergebnisse (Laboratory Observation) </i> (2015‑03‑26) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">elgabbr-</div></span><br />Version: Template 1.3.6.1.4.1.19376.1.3.1.6 <i>Laborergebnisse (Laboratory Observation) </i> (2015‑03‑26) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">elgabbr-</div></span></td></tr><tr class="explabel " style="vertical-align: top;"><td style="width: 20em; text-align: left;">Beispiel</td><td colspan="3" class="explabelgreen"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Strukturbeispiel Laborergebnis (Laboratory Observation)</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">ClinicalDocument</span><span class="ppsign">&gt;</span><br /><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="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- TemplateId für Laboratory Observation --&gt;<br /></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">1.3.6.1.4.1.19376.1.3.1.6</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Testidentifikation --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">id</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">OBS-1-4</span><span class="ppsign">"</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.2.16.1.99.3.1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Analyse/Testcode --&gt;<br /></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">26464-8</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">LOINC</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Leukozyten</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Verweis auf den narrativen Text --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#OBS-1-4</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">text</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Status des Laborergebnisses --&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;">    <span style="color:green">&lt;!-- medizinisch relevanter Zeitpunkt --&gt;<br /></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">20131201073406+0100</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">high</span> <span class="ppattribute">nullFlavor</span><span class="ppsign">="</span><span class="ppcontent">UNK</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;!-- Ergebnis der Analyse / des Tests --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">value</span> <span class="ppattribute">unit</span><span class="ppsign">="</span><span class="ppcontent">g/dL</span><span class="ppsign">"</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">16.0</span><span class="ppsign">"</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">PQ</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Bewertung des Ergebnisses --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">interpretationCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">N</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">HL7:ObservationInterpretation</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.5.83</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">normal</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Validator --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">participant</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">AUTHEN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext"> : </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;">    <span style="color:green">&lt;!-- Durchführende Instanz / externes Labor --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">performer</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">PRF</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext"> : </span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">performer</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 class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">ClinicalDocument</span><span class="ppsign">&gt;</span></span></tt></td></tr></table></td></tr><tr class="explabel " style="vertical-align: top;"><td style="width: 20em; text-align: left;">Beispiel</td><td colspan="3" class="explabelgreen"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Strukturbeispiel für ein Laborergebnis mit Cut-off-Wert (Datentyp IVL_PQ)</span></td></tr><tr><td><tt><span style="display: block;"><span style="color:green">&lt;!--So kann ein Wert von &gt; 500 mg/dl dargestellt und bewertet werden:--&gt;<br /></span></span><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">ClinicalDocument</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">IVL_PQ</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">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">500</span><span class="ppsign">"</span> <span class="ppattribute">unit</span><span class="ppsign">="</span><span class="ppcontent">mg/dl</span><span class="ppsign">"</span> <span class="ppattribute">inclusive</span><span class="ppsign">="</span><span class="ppcontent">false</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">high</span> <span class="ppattribute">nullFlavor</span><span class="ppsign">="</span><span class="ppcontent">PINF</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">value</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">interpretationCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent"> &gt;</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">High off scale</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.5.83 </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">ClinicalDocument</span><span class="ppsign">&gt;</span></span></tt></td></tr></table></td></tr><tr class="explabel " style="vertical-align: top;"><td style="width: 20em; text-align: left;">Beispiel</td><td colspan="3" class="explabelgreen"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Strukturbeispiel für ein in Arbeit befindliches Laborergebnis („Wert folgt“)</span></td></tr><tr><td><tt><span style="display: block;"><span style="color:green">&lt;!--Angabe von Parametern mit ausständigem Ergebnis:--&gt;<br /></span></span><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">ClinicalDocument</span><span class="ppsign">&gt;</span><br /><span style="display: block;">  <span style="color:green">&lt;!--Angabe von Parametern mit ausständigem Ergebnis:--&gt;<br /></span></span><span style="display: block;">  <span style="color:green">&lt;!--Laboratory Observation, Ergebnis noch nicht verfügbar (Wert folgt)--&gt;<br /></span></span><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="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.3.1.6</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="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">OBS-2-6</span><span class="ppsign">"</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.2.16.1.99.3.1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">10704-5</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">LOINC</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Wurmeier Stuhl</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">text</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#OBS-2-6</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">text</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Status des Laborergebnisses --&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">active</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="ppattribute">nullFlavor</span><span class="ppsign">="</span><span class="ppcontent">UNK</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">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">ST</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">Wert folgt</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">value</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Bewertung des Ergebnisses wird nicht angegeben [NP] --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">ClinicalDocument</span><span class="ppsign">&gt;</span></span></tt></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" 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 class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:observation<br /></strong></tt></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="">(atc...ion)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></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><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@moodCode<br /></strong></tt></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; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(atc...ion)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@root<br /></strong></tt></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.40.0.34.6.0.11.3.16</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(atc...ion)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@root<br /></strong></tt></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.3.6.1.4.1.19376.1.3.1.6</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Identifikation des Tests nach einer internen Codierung. Es gelten die Vorgaben des entsprechenden Kapitels des „Allgemeinen Implementierungsleitfadens“.<br /></td><td style="background-color: #FFEEEE;"><span title="">(atc...ion)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:code<br /></strong></tt></td></tr></table></td><td><strong>CE</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Codierung der Analyse / des Tests. <br /></td><td style="background-color: #FFEEEE;"><span title="">(atc...ion)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 1.2.40.0.34.10.44 <i>ELGA_Laborparameter </i>(DYNAMIC)</td></tr></table></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">[[File:Kred.png|14px]] 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">not(@nullFlavor) or not(@nullFlavor='OTH') or hl7:translation</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">Wenn code/@nullFlavor=OTH dann MUSS entweder code/translation anwesend sein.</span></td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:text<br /></strong></tt></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></strong></span></td><td><div>Der Text zum Laborergebnis wird verwendet, um einen Verweis zum narrativen Text herzustellen, Verwendung siehe 6.2.9.2 </div></td><td style="background-color: #FFEEEE;"><span title="">(atc...ion)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:statusCode<br /></strong></tt></td></tr></table></td><td><strong>CS</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><b>Statuscode</b>.<br />
 
<br />Auswahl:<br />
 
<br />Auswahl:<br />
 
<div>„<b>completed</b>“ für einen abgeschlossenen Test.</div>
 
<div>„<b>completed</b>“ für einen abgeschlossenen Test.</div>

Version vom 10. Mai 2019, 04:28 Uhr

Id1.2.40.0.34.6.0.11.3.16
ref
at-cda-bbr-
Gültigkeit2019‑05‑07 13:44:02
StatusKyellow.png EntwurfVersions-Label2019
Nameatcdabbr_entry_LaboratoryObservationAnzeigenameLaboratory Observation
KontextElternknoten des Template-Element mit Id 1.2.40.0.34.6.0.11.3.16
KlassifikationCDA Entry Level Template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Benutzt
Benutzt 2 Templates
Benutzt als NameVersion
1.2.40.0.34.11.4.3.2ContainmentKgreen.png Befundtext (Anmerkungen und Kommentare)DYNAMIC
1.2.40.0.34.11.4.3.3ContainmentKgreen.png Laboratory Performer 2DYNAMIC
BeziehungSpezialisierung: Template 1.3.6.1.4.1.19376.1.3.1.6 Laborergebnisse (Laboratory Observation) (2015‑03‑26)
ref
elgabbr-

Version: Template 1.3.6.1.4.1.19376.1.3.1.6 Laborergebnisse (Laboratory Observation) (2015‑03‑26)
ref
elgabbr-
Beispiel
Strukturbeispiel Laborergebnis (Laboratory Observation)
<ClinicalDocument>
  <observation classCode="OBS" moodCode="EVN">
    <!-- TemplateId für Laboratory Observation -->
    <templateId root="1.3.6.1.4.1.19376.1.3.1.6"/>    <!-- Testidentifikation -->
    <id extension="OBS-1-4" root="2.16.840.1.113883.2.16.1.99.3.1"/>    <!-- Analyse/Testcode -->
    <code code="26464-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Leukozyten"/>    <!-- Verweis auf den narrativen Text -->
    <text>
      <reference value="#OBS-1-4"/>    </text>    <!-- Status des Laborergebnisses -->
    <statusCode code="completed"/>    <!-- medizinisch relevanter Zeitpunkt -->
    <effectiveTime>
      <low value="20131201073406+0100"/>      <high nullFlavor="UNK"/>    </effectiveTime>    <!-- Ergebnis der Analyse / des Tests -->
    <value unit="g/dL" value="16.0" xsi:type="PQ"/>    <!-- Bewertung des Ergebnisses -->
    <interpretationCode code="N" codeSystemName="HL7:ObservationInterpretation" codeSystem="2.16.840.1.113883.5.83" displayName="normal"/>    <!-- Validator -->
    <participant typeCode="AUTHEN"> : </participant>    <!-- Durchführende Instanz / externes Labor -->
    <performer typeCode="PRF"> : </performer>  </observation></ClinicalDocument>
Beispiel
Strukturbeispiel für ein Laborergebnis mit Cut-off-Wert (Datentyp IVL_PQ)
<!--So kann ein Wert von > 500 mg/dl dargestellt und bewertet werden:-->
<ClinicalDocument>
  <value xsi:type="IVL_PQ">
    <low value="500" unit="mg/dl" inclusive="false"/>    <high nullFlavor="PINF"/>  </value>  <interpretationCode code=" >" displayName="High off scale" codeSystem="2.16.840.1.113883.5.83 "/></ClinicalDocument>
Beispiel
Strukturbeispiel für ein in Arbeit befindliches Laborergebnis („Wert folgt“)
<!--Angabe von Parametern mit ausständigem Ergebnis:-->
<ClinicalDocument>
  <!--Angabe von Parametern mit ausständigem Ergebnis:-->
  <!--Laboratory Observation, Ergebnis noch nicht verfügbar (Wert folgt)-->
  <observation classCode="OBS" moodCode="EVN">
    <templateId root="1.3.6.1.4.1.19376.1.3.1.6"/>    <id extension="OBS-2-6" root="2.16.840.1.113883.2.16.1.99.3.1"/>    <code code="10704-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Wurmeier Stuhl"/>    <text>
      <reference value="#OBS-2-6"/>    </text>    <!-- Status des Laborergebnisses -->
    <statusCode code="active"/>    <effectiveTime nullFlavor="UNK"/>    <value xsi:type="ST">Wert folgt</value>    <!-- Bewertung des Ergebnisses wird nicht angegeben [NP] -->
  </observation></ClinicalDocument>
ItemDTKardKonfBeschreibungLabel
hl7:observation
(atc...ion)
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(atc...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F1.2.40.0.34.6.0.11.3.16
Treetree.pnghl7:templateId
II1 … 1R(atc...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.1.6
Treetree.pnghl7:id
II0 … 1Identifikation des Tests nach einer internen Codierung. Es gelten die Vorgaben des entsprechenden Kapitels des „Allgemeinen Implementierungsleitfadens“.
(atc...ion)
Treetree.pnghl7:code
CE1 … 1RCodierung der Analyse / des Tests. 
(atc...ion)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 1.2.40.0.34.10.44 ELGA_Laborparameter (DYNAMIC)
 Schematron assertroleKred.png error 
 testnot(@nullFlavor) or not(@nullFlavor='OTH') or hl7:translation 
 MeldungWenn code/@nullFlavor=OTH dann MUSS entweder code/translation anwesend sein. 
Treetree.pnghl7:text
ED0 … 1
Der Text zum Laborergebnis wird verwendet, um einen Verweis zum narrativen Text herzustellen, Verwendung siehe 6.2.9.2 
(atc...ion)
Treetree.pnghl7:statusCode
CS1 … 1MStatuscode.


Auswahl:

„completed“ für einen abgeschlossenen Test.
„aborted“ für einen stornierten Test (konnte nicht durchgeführt werden)
„active“ für einen ausständigen Test („Wert folgt“)
(atc...ion)
 CONF
@code muss "completed" sein
oder
@code muss "aborted" sein
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1RMedizinisch relevantes Datum und Zeit. In der Regel Abnahmedatum/-zeit des Spezimen.
(atc...ion)
Auswahl0 … 1Elemente in der Auswahl:
  • hl7:value[@xsi:type='PQ']
  • hl7:value[@xsi:type='IVL_PQ']
  • hl7:value[@xsi:type='INT']
  • hl7:value[@xsi:type='IVL_INT']
  • hl7:value[@xsi:type='BL']
  • hl7:value[@xsi:type='ST']
  • hl7:value[@xsi:type='CV']
  • hl7:value[@xsi:type='TS']
  • hl7:value[@xsi:type='CD']
  • hl7:value[@xsi:type='RTO']
  • hl7:value[@xsi:type='RTO_QTY_QTY']
  • hl7:value[@xsi:type='RTO_PQ_PQ']
 ConstraintKonditionale Konformität:
  • Bei EIS "Basic" 1..1 R2 Codierung der Einheit erforderlich (im Element translation)
  • Bei EIS "Enhanced" 1..1 M Codierung der Einheit nach UCUM erforderlich
Datentyp eingeschränkt auf PQ, IVL_PQ, INT, IVL_INT, BL, ST, CV, TS, CD, RTO, RTO_QTY_QTY, RTO_PQ_PQ
Treeblank.pngTreetree.pnghl7:value
PQCErgebnis der Analyse codiert entsprechend dem Datentyp.
Kann bei stornierten Analysen entfallen.


Unterelemente können je nach Datentyp notwendig sein, z.B. high/low für IVL oder numerator/denominator für RTO.


(atc...ion)
Treeblank.pngTreeblank.png wo [@xsi:type='PQ']
Treeblank.pngTreeblank.pngTreetree.pnghl7:translation
PQR0 … 1Alternative Repräsentation derselben physikalischen Größe, mit unterschiedlicher Einheit in @code und @codeSystem und einem möglicherweise unterschiedlichen Wert.(atc...ion)
Treeblank.pngTreetree.pnghl7:value
IVL_PQC(atc...ion)
Treeblank.pngTreeblank.png wo [@xsi:type='IVL_PQ']
Treeblank.pngTreetree.pnghl7:value
INTC(atc...ion)
Treeblank.pngTreeblank.png wo [@xsi:type='INT']
Treeblank.pngTreetree.pnghl7:value
IVL_INTC(atc...ion)
Treeblank.pngTreeblank.png wo [@xsi:type='IVL_INT']
Treeblank.pngTreetree.pnghl7:value
BLC(atc...ion)
Treeblank.pngTreeblank.png wo [@xsi:type='BL']
Treeblank.pngTreetree.pnghl7:value
STC(atc...ion)
Treeblank.pngTreeblank.png wo [@xsi:type='ST']
Treeblank.pngTreetree.pnghl7:value
CVC(atc...ion)
Treeblank.pngTreeblank.png wo [@xsi:type='CV']
Treeblank.pngTreetree.pnghl7:value
TSC(atc...ion)
Treeblank.pngTreeblank.png wo [@xsi:type='TS']
Treeblank.pngTreetree.pnghl7:value
CDC(atc...ion)
Treeblank.pngTreeblank.png wo [@xsi:type='CD']
Treeblank.pngTreetree.pnghl7:value
RTOC(atc...ion)
Treeblank.pngTreeblank.png wo [@xsi:type='RTO']
Treeblank.pngTreetree.pnghl7:value
RTO_QTY_QTYC(atc...ion)
Treeblank.pngTreeblank.png wo [@xsi:type='RTO_QTY_QTY']
Treeblank.pngTreetree.pnghl7:value
RTO_PQ_PQC(atc...ion)
Treeblank.pngTreeblank.png wo [@xsi:type='RTO_PQ_PQ']
 Schematron assertroleKred.png error 
 testnot(hl7:value/@nullFlavor) 
 MeldungDie Verwendung von value/@nullFlavor ist nicht erlaubt 
Treetree.pnghl7:interpretationCode
CE0 … *Codierte Bewertung des Ergebnisses. Wird sowohl für Referenzbereichbewertungen als auch für die Codierung der RAST-Klassen verwendet.
(atc...ion)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 1.2.40.0.34.10.13 ELGA_ObservationInterpretation (DYNAMIC)
Treetree.pnghl7:entryRelationship
0 … *Beinhaltet 1.2.40.0.34.11.4.3.2 Befundtext (Anmerkungen und Kommentare) (DYNAMIC)(atc...ion)
Treeblank.png wo [hl7:act [hl7:code [(@code = '48767-8' and @codeSystem = '2.16.840.1.113883.6.1')]]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treetree.pnghl7:participant
0 … 1Validierende Person.
(atc...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FAUTHEN
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1R(atc...ion)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.3.1.5
Treeblank.pngTreetree.pnghl7:time
IVL_TS1 … 1R(atc...ion)
Treeblank.pngTreetree.pnghl7:participantRole
(atc...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1M(atc...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … 1R(atc...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL.AT1 … *R(atc...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:playingEntity
1 … 1M(atc...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … 1M(atc...ion)
Treetree.pnghl7:referenceRange
0 … *Es können mehrere Referenzbereiche angegeben werden.
(atc...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFV
 Beispiel
43.0% - 49.0% (im zugehörigen Section.text steht der entsprechende Text)
<referenceRange typeCode="REFV">
  <observationRange classCode="OBS" moodCode="EVN.CRT">
    <text>
      <reference value="#ref1"/>    </text>    <value xsi:type="IVL_PQ">
      <low value="43.0" unit="%"/>      <high value="49.0" unit="%"/>    </value>    <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" codeSystemName="HL7.ObservationInterpretation"/>  </observationRange></referenceRange>
 Beispiel
> 40.0% (im zugehörigen Section.text steht der entsprechende Text)
<referenceRange typeCode="REFV">
  <observationRange classCode="OBS" moodCode="EVN.CRT">
    <text>
      <reference value="#ref2"/>    </text>    <value xsi:type="IVL_PQ">
      <low value="40.0" unit="%" inclusive="false"/>    </value>    <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" codeSystemName="HL7.ObservationInterpretation"/>  </observationRange></referenceRange>
 Beispiel
Phase 1: 43.0 - 49.0 Phase 2: 45.0 – 55.0 1835 Phase 3: 49.0 – 63.0 (im zugehörigen Section.text steht der entsprechende Text)
<referenceRange typeCode="REFV">
  <observationRange classCode="OBS" moodCode="EVN.CRT">
    <text>
      <reference value="#ref3"/>    </text>    <interpretationCode code="H" codeSystem="2.16.840.1.113883.5.83"/>  </observationRange></referenceRange>
 Beispiel
> 40.0% (im zugehörigen Section.text steht der entsprechende Text)
<referenceRange typeCode="REFV">
  <observationRange classCode="OBS" moodCode="EVN.CRT">
    <text>
      <reference value="#ref4"/>    </text>    <value xsi:type="IVL_PQ">
      <low value="40.0" unit="%" inclusive="false"/>      <high nullFlavor="PINF"/>    </value>  </observationRange></referenceRange>
 Beispiel
150 - 360 G/L (im zugehörigen Section.text steht der entsprechende Text)
<referenceRange typeCode="REFV">
  <observationRange classCode="OBS" moodCode="EVN.CRT">
    <text>
      <reference value="#ref5"/>    </text>    <value xsi:type="IVL_PQ">
      <low value="150" unit="G/L"/>      <high value="360" unit="G/L"/>    </value>    <interpretationCode code="N" codeSystemName="HL7:ObservationInterpretation" codeSystem="2.16.840.1.113883.5.83" displayName="normal"/>  </observationRange></referenceRange>
Treeblank.pngTreetree.pnghl7:observationRange
1 … 1M(atc...ion)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FOBS
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs1 … 1FEVN.CRT
Treeblank.pngTreeblank.pngTreetree.pnghl7:text
ED1 … 1M(atc...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:reference
TEL1 … 1M(atc...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
IVL_PQ0 … 1(atc...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:low
PQ1 … 1R(atc...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:high
PQ1 … 1R(atc...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:interpretationCode
CE1 … 1M(atc...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF1 … 1FN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.5.83 (Observation Interpretation)
Treetree.pnghl7:performer
0 … *Externes Labor.
Beinhaltet 1.2.40.0.34.11.4.3.3 Laboratory Performer 2 (DYNAMIC)		(atc...ion)
Abgerufen von „http://wiki.hl7.at/index.php?title=1.2.40.0.34.6.0.11.3.16/static-2019-05-07T134402&oldid=106683“