1.2.40.0.34.6.0.11.2.96/static-2020-07-29T142356: 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;">1.2.40.0.34.6.0.11.2.96 <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;">2020‑07‑29 14:23:56</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;">2020</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">atcdabbr_section_DiagnoseKodiert</td><th style="width: 20em; text-align: left;">Anzeigename</th><td style="text-align: left;">Diagnose - kodiert</td></tr><td style="text-align: left;" colspan="4"><table class="treetable" id="templateDescTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Beschreibung</td></tr><tr><td><div>Alle in dieser Behandlung verwendeten Diagnosen, wie die ursprüngliche Diagnosen des Behandlungsgrunds als auch alle weiteren während der Behandlung zu beachtenden Diagnosen, sind hier maschinenlesbar zu dokumentieren.</div></td></tr></table></td><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 1.2.40.0.34.6.0.11.2.96</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Section 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">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 class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Benutzt 4 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;">1.2.40.0.34.6.0.11.9.36</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Author Body (2019)</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:Kyellow.png|14px]] Informant Body (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.7</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Problem Concern Entry (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.8</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Übersetzung (2019)</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></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="explabelblue"><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">Beispiel</span></td></tr><tr><td><span style="font-family: 'Courier';"><span style="display: block;"><span style="color:green">&lt;!-- Diagnose<br /> Alle in dieser Behandlung verwendeten Diagnosen, wie die ursprüngliche Diagnosen des Behandlungsgrunds als auch alle weiteren während der Behandlung zu beachtenden Diagnosen, sind hier maschinenlesbar zu dokumentieren.--&gt;<br /></span></span><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">component</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">section</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">1.2.40.0.34.6.0.11.2.96</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">439401001</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="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">title</span><span class="ppsign">&gt;</span><span class="pptext">Diagnose</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">title</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 class="pptext"><br />          Diagnosen am Ende der Behandlung:</span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">br</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">content</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">disdiag1</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br />        <span class="pptext">* </span><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppelement">content</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">disdiag1_diagnosis</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">HFrEF, MI Grad I-II</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">content</span><span class="ppsign">&gt;</span></span>        <span class="pptext">, EF mittergradig eingeschränkt, Al Grad I (Echo 08/18), diffuse KHK (CAG 07/18), Z.n. ventrikulärer Tachykardie mit CPR 07/18 (Ursache DD QT Verlängerung unter Psychopharmaka plus Antibiothikatherapie), parosymales Vorhofflimmern/-flattern, Linksschenkelblock</span>      <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">content</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">br</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">content</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">disdiag2</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br />        <span class="pptext">* </span><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppelement">content</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">disdiag2_diagnosis</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">Z.n. akutem prärenalen Nierenversagen</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">content</span><span class="ppsign">&gt;</span></span>        <span class="pptext"> 07/18</span>      <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">content</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">br</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>      <span class="pptext"><br /> * arterielle Hypertonie</span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">br</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>      <span class="pptext"><br /> * Hypercholesterinämie</span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">br</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>      <span class="pptext"><br /> * Z.n. ACM Infarkt rechts 08/16 (kardioembolisch) mit Hemisymptomatik links</span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">br</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>      <span class="pptext"><br /> * Z.n. einmaligem GM-Anfall 04/17</span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">br</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>      <span class="pptext"><br /> * Z.n. multiplen TVT beidseits</span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">br</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>      <span class="pptext"><br /> * Z.n. Motorradumfall 2016 mit instabilem Becken (Beckentrauma, multiple Gefäßverletzungen (Stent Versorgung, Sehenenruptur linke Schulter)</span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">br</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>      <span class="pptext"><br /> * reaktiv chronische Depression seit Motoradumfall</span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">br</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>      <span class="pptext"><br /> * aktuell: leichter Atemwegsinfekt, sowie Mikrohämaturie und diskrete Dysurie (DD asymptomatischer Harnwegsinfekt) ohne systematische Infektzeichen<br />          </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;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">author</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">time</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20181213083800+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">assignedAuthor</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppelement">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.99.4</span><span class="ppsign">"</span> <span class="ppattribute">assigningAuthorityName</span><span class="ppsign">="</span><span class="ppcontent">Facharztpraxis für Innere Medizin, Niere, Bluthochdruck und Ernährungsmedizin - Dr. med. univ. Daniela Holzer</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">assignedPerson</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">name</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppelement">prefix</span> <span class="ppattribute">qualifier</span><span class="ppsign">="</span><span class="ppcontent">AC</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">Dr.</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">prefix</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppelement">given</span><span class="ppsign">&gt;</span><span class="pptext">Daniela</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">given</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppelement">family</span><span class="ppsign">&gt;</span><span class="pptext">Holzer</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">family</span><span class="ppsign">&gt;</span></span>          <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">name</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">assignedPerson</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">assignedAuthor</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">author</span><span class="ppsign">&gt;</span></span>    <span class="pptext"><br />            <br />            ::<br />            <br />          </span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">component</span><span class="ppsign">&gt;</span></span></span></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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">hl7:section<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="">(atc...ert)</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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">@classCode<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">DOCSECT</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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">@moodCode<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">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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">hl7:templateId<br xmlns="http://www.w3.org/1999/xhtml" /></span></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>HL7 Austria - Diagnose - kodiert<br /></td><td style="background-color: #FFEEEE;"><span title="">(atc...ert)</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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">@root<br xmlns="http://www.w3.org/1999/xhtml" /></span></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">1.2.40.0.34.6.0.11.2.96</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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">hl7:id<br xmlns="http://www.w3.org/1999/xhtml" /></span></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>Eindeutige ID der Sektion</td><td style="background-color: #FFEEEE;"><span title="">(atc...ert)</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; 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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">hl7:code<br xmlns="http://www.w3.org/1999/xhtml" /></span></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>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(atc...ert)</span></td></tr><tr style="vertical-align: top;"><td><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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">@code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td rowspan="2" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">423100009</td></tr><tr style="vertical-align: top;"><td><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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">@codeSystem<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.6.96 (Snomed-CT)</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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">hl7:title<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>ST</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...ert)</span></td></tr><tr style="vertical-align: top; background-color: #FFEEEE;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4" style="background-color: white;"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>Elementinhalt muss "Diagnose" sein</td></tr></table></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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">hl7:text<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>SD.TEXT</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>Enthält Informationen für den menschlichen Leser</td><td style="background-color: #FFEEEE;"><span title="">(atc...ert)</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><span xmlns="" style="font-family: 'Courier'; 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></strong></span></td><td>Author der enthaltenen Information (GDA)<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="">(atc...ert)</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><span xmlns="" style="font-family: 'Courier'; 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></strong></span></td><td><div>Quelle für die enthaltene Information</div><div>Name der Person und ihre Beziehung zum Patienten (Patient oder Angehöriger, Auskunftsperson - nicht-GDA)</div><br />Beinhaltet 1.2.40.0.34.6.0.11.9.3 <i>Informant Body</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(atc...ert)</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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">hl7:entry<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></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>Beinhaltet 1.2.40.0.34.6.0.11.3.7 <i>Problem Concern Entry</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(atc...ert)</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><span xmlns="" style="font-family: 'Courier'; 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">DRIV</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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">hl7:component<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>Optionale Subsections zur Angabe von Übersetzungen des Elements<br /><br />Beinhaltet 1.2.40.0.34.6.0.11.2.8 <i>Übersetzung</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(atc...ert)</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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">@typeCode<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">COMP</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><span xmlns="" style="font-family: 'Courier'; 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>
+
<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;">1.2.40.0.34.6.0.11.2.96 <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;">2020‑07‑29 14:23:56</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;">2020</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">atcdabbr_section_DiagnoseKodiert</td><th style="width: 20em; text-align: left;">Anzeigename</th><td style="text-align: left;">Diagnose - kodiert</td></tr><td style="text-align: left;" colspan="4"><table class="treetable" id="templateDescTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Beschreibung</td></tr><tr><td><div>Alle in dieser Behandlung verwendeten Diagnosen, wie die ursprüngliche Diagnosen des Behandlungsgrunds als auch alle weiteren während der Behandlung zu beachtenden Diagnosen, sind hier maschinenlesbar zu dokumentieren.</div></td></tr></table></td><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 1.2.40.0.34.6.0.11.2.96</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Section 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">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 class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Benutzt 4 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;">1.2.40.0.34.6.0.11.9.36</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Author Body (2019)</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:Kyellow.png|14px]] Informant Body (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.7</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Problem Concern Entry (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.8</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Übersetzung (2019)</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></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="explabelblue"><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">Beispiel</span></td></tr><tr><td><span style="font-family: 'Courier';"><span style="display: block;"><span style="color:green">&lt;!-- Diagnose<br /> Alle in dieser Behandlung verwendeten Diagnosen, wie die ursprüngliche Diagnosen des Behandlungsgrunds als auch alle weiteren während der Behandlung zu beachtenden Diagnosen, sind hier maschinenlesbar zu dokumentieren.--&gt;<br /></span></span><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">component</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">section</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">1.2.40.0.34.6.0.11.2.96</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">439401001</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="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">title</span><span class="ppsign">&gt;</span><span class="pptext">Diagnose</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">title</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 class="pptext"><br />          Diagnosen am Ende der Behandlung:</span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">br</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">content</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">disdiag1</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br />        <span class="pptext">* </span><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppelement">content</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">disdiag1_diagnosis</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">HFrEF, MI Grad I-II</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">content</span><span class="ppsign">&gt;</span></span>        <span class="pptext">, EF mittergradig eingeschränkt, Al Grad I (Echo 08/18), diffuse KHK (CAG 07/18), Z.n. ventrikulärer Tachykardie mit CPR 07/18 (Ursache DD QT Verlängerung unter Psychopharmaka plus Antibiothikatherapie), parosymales Vorhofflimmern/-flattern, Linksschenkelblock</span>      <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">content</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">br</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">content</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">disdiag2</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br />        <span class="pptext">* </span><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppelement">content</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">disdiag2_diagnosis</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">Z.n. akutem prärenalen Nierenversagen</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">content</span><span class="ppsign">&gt;</span></span>        <span class="pptext"> 07/18</span>      <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">content</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">br</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>      <span class="pptext"><br /> * arterielle Hypertonie</span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">br</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>      <span class="pptext"><br /> * Hypercholesterinämie</span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">br</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>      <span class="pptext"><br /> * Z.n. ACM Infarkt rechts 08/16 (kardioembolisch) mit Hemisymptomatik links</span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">br</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>      <span class="pptext"><br /> * Z.n. einmaligem GM-Anfall 04/17</span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">br</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>      <span class="pptext"><br /> * Z.n. multiplen TVT beidseits</span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">br</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>      <span class="pptext"><br /> * Z.n. Motorradumfall 2016 mit instabilem Becken (Beckentrauma, multiple Gefäßverletzungen (Stent Versorgung, Sehenenruptur linke Schulter)</span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">br</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>      <span class="pptext"><br /> * reaktiv chronische Depression seit Motoradumfall</span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">br</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>      <span class="pptext"><br /> * aktuell: leichter Atemwegsinfekt, sowie Mikrohämaturie und diskrete Dysurie (DD asymptomatischer Harnwegsinfekt) ohne systematische Infektzeichen<br />          </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;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">author</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">time</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20181213083800+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">assignedAuthor</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppelement">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.99.4</span><span class="ppsign">"</span> <span class="ppattribute">assigningAuthorityName</span><span class="ppsign">="</span><span class="ppcontent">Facharztpraxis für Innere Medizin, Niere, Bluthochdruck und Ernährungsmedizin - Dr. med. univ. Daniela Holzer</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">assignedPerson</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">name</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppelement">prefix</span> <span class="ppattribute">qualifier</span><span class="ppsign">="</span><span class="ppcontent">AC</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">Dr.</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">prefix</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppelement">given</span><span class="ppsign">&gt;</span><span class="pptext">Daniela</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">given</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppelement">family</span><span class="ppsign">&gt;</span><span class="pptext">Holzer</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">family</span><span class="ppsign">&gt;</span></span>          <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">name</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">assignedPerson</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">assignedAuthor</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">author</span><span class="ppsign">&gt;</span></span>    <span class="pptext"><br />            <br />            ::<br />            <br />          </span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">component</span><span class="ppsign">&gt;</span></span></span></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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">hl7:section<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="">(atc...ert)</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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">@classCode<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">DOCSECT</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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">@moodCode<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">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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">hl7:templateId<br xmlns="http://www.w3.org/1999/xhtml" /></span></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>HL7 Austria - Diagnose - kodiert<br />
<!--d81cef7e46c64a7f6903d75fe76030f61bc3f0de-->
+
                </td><td style="background-color: #FFEEEE;"><span title="">(atc...ert)</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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">@root<br xmlns="http://www.w3.org/1999/xhtml" /></span></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">1.2.40.0.34.6.0.11.2.96</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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">hl7:id<br xmlns="http://www.w3.org/1999/xhtml" /></span></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>Eindeutige ID der Sektion</td><td style="background-color: #FFEEEE;"><span title="">(atc...ert)</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; 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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">hl7:code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CE.IPS</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...ert)</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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">@code<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">439401001</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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">@codeSystem<br xmlns="http://www.w3.org/1999/xhtml" /></span></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">2.16.840.1.113883.6.96</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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">@codeSystemName<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>st</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">SNOMED CT</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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">@displayName<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>st</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">Diagnosis</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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">hl7:translation<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>Hier können Code-Übersetzungen, aus dem selben Codesystem oder auch aus weiteren Codesystemen, bereitgestellt werden.</td><td style="background-color: #FFEEEE;"><span title="">(atc...ert)</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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">@code<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>R</td><td style="vertical-align: top;" colspan="2"></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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">@codeSystem<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2"></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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">@codeSystemName<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>st</td><td><span><strong>0 … 1</strong></span></td><td> </td><td style="vertical-align: top;" colspan="2"></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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">@displayName<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>st</td><td><span><strong>0 … 1</strong></span></td><td> </td><td style="vertical-align: top;" colspan="2"></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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">ips:designation<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>ST</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Hier können sprachliche Übersetzungen des hier verwendeten Codes bereitgestellt werden.</td><td style="background-color: #FFEEEE;"><span title="">(atc...ert)</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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">@language<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>R</td><td style="vertical-align: top;" colspan="2"></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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">hl7:title<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>ST</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...ert)</span></td></tr><tr style="vertical-align: top; background-color: #FFEEEE;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4" style="background-color: white;"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>Elementinhalt muss "Diagnose" sein</td></tr></table></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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">hl7:text<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>SD.TEXT</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>Enthält Informationen für den menschlichen Leser</td><td style="background-color: #FFEEEE;"><span title="">(atc...ert)</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><span xmlns="" style="font-family: 'Courier'; 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></strong></span></td><td>Author der enthaltenen Information (GDA)<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="">(atc...ert)</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><span xmlns="" style="font-family: 'Courier'; 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></strong></span></td><td>
 +
                    <div>Quelle für die enthaltene Information</div>
 +
                    <div>Name der Person und ihre Beziehung zum Patienten (Patient oder Angehöriger, Auskunftsperson - nicht-GDA)</div>
 +
                <br />Beinhaltet 1.2.40.0.34.6.0.11.9.3 <i>Informant Body</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(atc...ert)</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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">hl7:entry<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></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>Beinhaltet 1.2.40.0.34.6.0.11.3.7 <i>Problem Concern Entry</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(atc...ert)</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><span xmlns="" style="font-family: 'Courier'; 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">DRIV</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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">hl7:component<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>Optionale Subsections zur Angabe von Übersetzungen des Elements<br />
 +
                <br />Beinhaltet 1.2.40.0.34.6.0.11.2.8 <i>Übersetzung</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(atc...ert)</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><span xmlns="" style="font-family: 'Courier'; font-weight: bold;">@typeCode<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">COMP</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><span xmlns="" style="font-family: 'Courier'; 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>
 +
<!--f4548d7ea2cdfc36cc96c341cbdfac48e5fc1ac1-->

Version vom 20. August 2020, 13:47 Uhr

Id1.2.40.0.34.6.0.11.2.96
ref
at-cda-bbr-
Gültigkeit2020‑07‑29 14:23:56
StatusKyellow.png EntwurfVersions-Label2020
Nameatcdabbr_section_DiagnoseKodiertAnzeigenameDiagnose - kodiert
Beschreibung
Alle in dieser Behandlung verwendeten Diagnosen, wie die ursprüngliche Diagnosen des Behandlungsgrunds als auch alle weiteren während der Behandlung zu beachtenden Diagnosen, sind hier maschinenlesbar zu dokumentieren.
KontextElternknoten des Template-Element mit Id 1.2.40.0.34.6.0.11.2.96
KlassifikationCDA Section level template
Offen/GeschlossenGeschlossen (nur definierte Elemente sind erlaubt)
Benutzt
Benutzt 4 Templates
Benutzt als NameVersion
1.2.40.0.34.6.0.11.9.36ContainmentKyellow.png Author Body (2019)DYNAMIC
1.2.40.0.34.6.0.11.9.3ContainmentKyellow.png Informant Body (2019)DYNAMIC
1.2.40.0.34.6.0.11.3.7ContainmentKyellow.png Problem Concern Entry (2019)DYNAMIC
1.2.40.0.34.6.0.11.2.8ContainmentKyellow.png Übersetzung (2019)DYNAMIC
Beispiel
Beispiel
<!-- Diagnose
Alle in dieser Behandlung verwendeten Diagnosen, wie die ursprüngliche Diagnosen des Behandlungsgrunds als auch alle weiteren während der Behandlung zu beachtenden Diagnosen, sind hier maschinenlesbar zu dokumentieren.-->
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Diagnosen am Ende der Behandlung:
      <br/>      <content ID="disdiag1">
        *         <content ID="disdiag1_diagnosis">HFrEF, MI Grad I-II</content>        , EF mittergradig eingeschränkt, Al Grad I (Echo 08/18), diffuse KHK (CAG 07/18), Z.n. ventrikulärer Tachykardie mit CPR 07/18 (Ursache DD QT Verlängerung unter Psychopharmaka plus Antibiothikatherapie), parosymales Vorhofflimmern/-flattern, Linksschenkelblock      </content>
      <br/>      <content ID="disdiag2">
        *         <content ID="disdiag2_diagnosis">Z.n. akutem prärenalen Nierenversagen</content>         07/18      </content>
      <br/>      
* arterielle Hypertonie
      <br/>      
* Hypercholesterinämie
      <br/>      
* Z.n. ACM Infarkt rechts 08/16 (kardioembolisch) mit Hemisymptomatik links
      <br/>      
* Z.n. einmaligem GM-Anfall 04/17
      <br/>      
* Z.n. multiplen TVT beidseits
      <br/>      
* Z.n. Motorradumfall 2016 mit instabilem Becken (Beckentrauma, multiple Gefäßverletzungen (Stent Versorgung, Sehenenruptur linke Schulter)
      <br/>      
* reaktiv chronische Depression seit Motoradumfall
      <br/>      
* aktuell: leichter Atemwegsinfekt, sowie Mikrohämaturie und diskrete Dysurie (DD asymptomatischer Harnwegsinfekt) ohne systematische Infektzeichen
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      <time value="20181213083800+0100"/>      <assignedAuthor>
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          <name>
            <prefix qualifier="AC">Dr.</prefix>            <given>Daniela</given>            <family>Holzer</family>          </name>
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      </assignedAuthor>
    </author>
    

 ::

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 CONF
Elementinhalt muss "Diagnose" sein
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(atc...ert)
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0 … *
Quelle für die enthaltene Information
Name der Person und ihre Beziehung zum Patienten (Patient oder Angehöriger, Auskunftsperson - nicht-GDA)

Beinhaltet 1.2.40.0.34.6.0.11.9.3 Informant Body (DYNAMIC)
(atc...ert)
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0 … *ROptionale Subsections zur Angabe von Übersetzungen des Elements

Beinhaltet 1.2.40.0.34.6.0.11.2.8 Übersetzung (DYNAMIC)
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