1.2.40.0.34.11.5.2.9/static-2012-01-12T000000: 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;">1.2.40.0.34.11.5.2.9</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2012‑01‑12</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kgreen.png|14px]] Aktiv</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;"></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">Befund</td><th style="width: 20em; text-align: left;">Anzeigename</th><td style="text-align: left;">Befund</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 1.2.40.0.34.11.5.2.9</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">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;">1.2.40.0.34.11.5.3.2</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Kodierung des Befundtextes</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.11.5.3.1</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] BI-RADS® Klassifikation</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beziehung</th><td style="text-align: left;" colspan="3">Version: Template 1.2.40.0.34.11.5.2.9 <i> </i> (2012‑01‑12)</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 Allgemein</span></td></tr><tr><td><tt><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">1.2.40.0.34.11.5.2.9</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- Code der Sektion --&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">18782-3</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Study observation</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="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- Titel der Sektion --&gt;<br /></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">Befund</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;">  <span style="color:green">&lt;!-- Textbereich der Sektion --&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><span class="pptext"> ... Lesbarer Textbereich ... </span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">section</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 Mammographie mit BI-RADS® Klassifikation</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</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="ppnamespace">hl7:</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="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.11.5.2.9</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Code der Sektion --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">18782-3</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Study observation</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="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Titel der Sektion --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">title</span><span class="ppsign">&gt;</span><span class="pptext">Befund</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">title</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Textbereich der Sektion --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</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="ppnamespace">hl7:</span><span class="ppelement">paragraph</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">content</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">finding-1</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext"> Parenchymasymmetrie. Verkalkte Ölcyste li. Sonst unauffälliger Befund bei Zustand nach Reduktionsplastik bds., derzeit kein Malignomhinweis. </span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">content</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">paragraph</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">table</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">thead</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">th</span><span class="ppsign">&gt;</span><span class="pptext">Klassifikation</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">th</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">th</span><span class="ppsign">&gt;</span><span class="pptext">Wert</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">th</span><span class="ppsign">&gt;</span></span>          <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">thead</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">tbody</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">&gt;</span><span class="pptext">BI-RADS</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">birads</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">4A</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span>          <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">&gt;</span><span class="pptext">ACR</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">acr</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">2</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span>          <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">tbody</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">table</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Maschinenlesbare Elemente der Sektion --&gt;<br /></span></span><span style="display: block;">    <span style="color:green">&lt;!-- Entry fuer die Codierung des Befundtextes --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">entry</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</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;!-- Text Observation --&gt;<br /></span></span><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.11.5.3.2</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="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.10.20.6.2.12</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="ppnamespace">hl7:</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">121071</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.840.10008.2.16.4</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">DCM</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Finding</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="ppnamespace">hl7:</span><span class="ppelement">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">ED</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#finding1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">entry</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- entry fuer ELGA BI-RADS® Codierung --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">entry</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</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;!-- Mammography Observation --&gt;<br /></span></span><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.11.5.3.1</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="ppnamespace">hl7:</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">36625-2</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">Breast Mammogram</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="ppnamespace">hl7:</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="ppnamespace">hl7:</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#birads</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</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="ppnamespace">hl7:</span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">completed</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">effectiveTime</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20110830103000+02</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="ppnamespace">hl7:</span><span class="ppelement">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">CD</span><span class="ppsign">"</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">MA.II.A.5.4A</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.5.49</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">ELGA_MammogramAssessment</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">entry</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">section</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</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:section<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="">(Befund)</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>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">DOCSECT</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="">(Befund)</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">1.2.40.0.34.11.5.2.9</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>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Befund)</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><tt><strong>@code<br /></strong></tt></td></tr></table></td><td rowspan="4" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">18782-3</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><tt><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.6.1 (LOINC)</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><tt><strong>@codeSystemName<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">LOINC</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><tt><strong>@displayName<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">Study observation</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:title<br /></strong></tt></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="">(Befund)</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 "Befund" 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><tt><strong>hl7:text<br /></strong></tt></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><div>Befundtext sollte in Abschnitte (&lt;paragraph&gt;) gegliedert sein. Vorgegebene Struktur für Mammographie: Klassifikationen nach BI-RADS® oder nach ACR Index MÜSSEN im Textteil als Tabelle enthalten sein.</div><div>Empfohlen wird die Angabe der BI-RADS® Klassen in arabischen Ziffern.</div></td><td style="background-color: #FFEEEE;"><span title="">(Befund)</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:entry<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>Beinhaltet 1.2.40.0.34.11.5.3.2 <i>Kodierung des Befundtextes</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Befund)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> wo  <i> [hl7:observation [hl7:code [(@code = '121071' and @codeSystem = '1.2.840.10008.2.16.4')]]]</i></td></tr></table></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><tt><strong>hl7:entry<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>Beinhaltet 1.2.40.0.34.11.5.3.1 <i>BI-RADS® Klassifikation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Befund)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> wo  <i> [hl7:observation [hl7:code [(@code = '36625-2' and @codeSystem = '2.16.840.1.113883.6.1')]]]</i></td></tr></table></td><td></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;">1.2.40.0.34.11.5.2.9</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2012‑01‑12</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kgreen.png|14px]] Aktiv</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;"></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">Befund</td><th style="width: 20em; text-align: left;">Anzeigename</th><td style="text-align: left;">Befund</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 1.2.40.0.34.11.5.2.9</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">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;">1.2.40.0.34.11.5.3.2</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Kodierung des Befundtextes</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.11.5.3.1</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] BI-RADS® Klassifikation</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beziehung</th><td style="text-align: left;" colspan="3">Version: Template 1.2.40.0.34.11.5.2.9 <i>Befund </i> (2012‑01‑12) <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 Allgemein</span></td></tr><tr><td><tt><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">1.2.40.0.34.11.5.2.9</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- Code der Sektion --&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">18782-3</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Study observation</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="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- Titel der Sektion --&gt;<br /></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">Befund</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;">  <span style="color:green">&lt;!-- Textbereich der Sektion --&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><span class="pptext"> ... Lesbarer Textbereich ... </span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">section</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 Mammographie mit BI-RADS® Klassifikation</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</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="ppnamespace">hl7:</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="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.11.5.2.9</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Code der Sektion --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">18782-3</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Study observation</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="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Titel der Sektion --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">title</span><span class="ppsign">&gt;</span><span class="pptext">Befund</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">title</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Textbereich der Sektion --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</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="ppnamespace">hl7:</span><span class="ppelement">paragraph</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">content</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">finding-1</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext"> Parenchymasymmetrie. Verkalkte Ölcyste li. Sonst unauffälliger Befund bei Zustand nach Reduktionsplastik bds., derzeit kein Malignomhinweis. </span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">content</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">paragraph</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">table</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">thead</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">th</span><span class="ppsign">&gt;</span><span class="pptext">Klassifikation</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">th</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">th</span><span class="ppsign">&gt;</span><span class="pptext">Wert</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">th</span><span class="ppsign">&gt;</span></span>          <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">thead</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">tbody</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">&gt;</span><span class="pptext">BI-RADS</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">birads</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">4A</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span>          <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">&gt;</span><span class="pptext">ACR</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">acr</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">2</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span>          <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">tbody</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">table</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Maschinenlesbare Elemente der Sektion --&gt;<br /></span></span><span style="display: block;">    <span style="color:green">&lt;!-- Entry fuer die Codierung des Befundtextes --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">entry</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</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;!-- Text Observation --&gt;<br /></span></span><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.11.5.3.2</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="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.10.20.6.2.12</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="ppnamespace">hl7:</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">121071</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.840.10008.2.16.4</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">DCM</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Finding</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="ppnamespace">hl7:</span><span class="ppelement">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">ED</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#finding1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">entry</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- entry fuer ELGA BI-RADS® Codierung --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">entry</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</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;!-- Mammography Observation --&gt;<br /></span></span><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.11.5.3.1</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="ppnamespace">hl7:</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">36625-2</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">Breast Mammogram</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="ppnamespace">hl7:</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="ppnamespace">hl7:</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#birads</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</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="ppnamespace">hl7:</span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">completed</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">effectiveTime</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20110830103000+02</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="ppnamespace">hl7:</span><span class="ppelement">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">CD</span><span class="ppsign">"</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">MA.II.A.5.4A</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.5.49</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">ELGA_MammogramAssessment</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">entry</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">section</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</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:section<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="">(Befund)</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>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">DOCSECT</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="">(Befund)</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">1.2.40.0.34.11.5.2.9</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>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Befund)</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><tt><strong>@code<br /></strong></tt></td></tr></table></td><td rowspan="4" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">18782-3</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><tt><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.6.1 (LOINC)</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><tt><strong>@codeSystemName<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">LOINC</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><tt><strong>@displayName<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">Study observation</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:title<br /></strong></tt></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="">(Befund)</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 "Befund" 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><tt><strong>hl7:text<br /></strong></tt></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><div>Befundtext sollte in Abschnitte (&lt;paragraph&gt;) gegliedert sein. Vorgegebene Struktur für Mammographie: Klassifikationen nach BI-RADS® oder nach ACR Index MÜSSEN im Textteil als Tabelle enthalten sein.</div><div>Empfohlen wird die Angabe der BI-RADS® Klassen in arabischen Ziffern.</div></td><td style="background-color: #FFEEEE;"><span title="">(Befund)</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:entry<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>Beinhaltet 1.2.40.0.34.11.5.3.2 <i>Kodierung des Befundtextes</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Befund)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> wo  <i> [hl7:observation [hl7:code [(@code = '121071' and @codeSystem = '1.2.840.10008.2.16.4')]]]</i></td></tr></table></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><tt><strong>hl7:entry<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>Beinhaltet 1.2.40.0.34.11.5.3.1 <i>BI-RADS® Klassifikation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Befund)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> wo  <i> [hl7:observation [hl7:code [(@code = '36625-2' and @codeSystem = '2.16.840.1.113883.6.1')]]]</i></td></tr></table></td><td></td></tr></table></td></tr></table>

Version vom 18. Januar 2019, 14:12 Uhr

Id1.2.40.0.34.11.5.2.9Gültigkeit2012‑01‑12
StatusKgreen.png AktivVersions-Label
NameBefundAnzeigenameBefund
KontextElternknoten des Template-Element mit Id 1.2.40.0.34.11.5.2.9
KlassifikationCDA Section level template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Benutzt
Benutzt 2 Templates
Benutzt als NameVersion
1.2.40.0.34.11.5.3.2ContainmentKgreen.png Kodierung des BefundtextesDYNAMIC
1.2.40.0.34.11.5.3.1ContainmentKgreen.png BI-RADS® KlassifikationDYNAMIC
BeziehungVersion: Template 1.2.40.0.34.11.5.2.9 Befund (2012‑01‑12)
ref
elgabbr-
Beispiel
Strukturbeispiel Allgemein
<section>
  <templateId root="1.2.40.0.34.11.5.2.9"/>  <!-- Code der Sektion -->
  <code code="18782-3" displayName="Study observation" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <!-- Titel der Sektion -->
  <title>Befund</title>  <!-- Textbereich der Sektion -->
  <text> ... Lesbarer Textbereich ... </text></section>
Beispiel
Strukturbeispiel Mammographie mit BI-RADS® Klassifikation
<hl7:ClinicalDocument>
  <hl7:section>
    <hl7:templateId root="1.2.40.0.34.11.5.2.9"/>    <!-- Code der Sektion -->
    <hl7:code code="18782-3" displayName="Study observation" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>    <!-- Titel der Sektion -->
    <hl7:title>Befund</hl7:title>    <!-- Textbereich der Sektion -->
    <hl7:text>
      <hl7:paragraph>
        <hl7:content ID="finding-1"> Parenchymasymmetrie. Verkalkte Ölcyste li. Sonst unauffälliger Befund bei Zustand nach Reduktionsplastik bds., derzeit kein Malignomhinweis. </hl7:content>      </hl7:paragraph>      <hl7:table>
        <hl7:thead>
          <hl7:tr>
            <hl7:th>Klassifikation</hl7:th>            <hl7:th>Wert</hl7:th>          </hl7:tr>        </hl7:thead>        <hl7:tbody>
          <hl7:tr>
            <hl7:td>BI-RADS</hl7:td>            <hl7:td ID="birads">4A</hl7:td>          </hl7:tr>          <hl7:tr>
            <hl7:td>ACR</hl7:td>            <hl7:td ID="acr">2</hl7:td>          </hl7:tr>        </hl7:tbody>      </hl7:table>    </hl7:text>    <!-- Maschinenlesbare Elemente der Sektion -->
    <!-- Entry fuer die Codierung des Befundtextes -->
    <hl7:entry>
      <hl7:observation classCode="OBS" moodCode="EVN">
        <!-- Text Observation -->
        <hl7:templateId root="1.2.40.0.34.11.5.3.2"/>        <hl7:templateId root="2.16.840.1.113883.10.20.6.2.12"/>        <hl7:code code="121071" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Finding"/>        <hl7:value xsi:type="ED">
          <hl7:reference value="#finding1"/>        </hl7:value>      </hl7:observation>    </hl7:entry>    <!-- entry fuer ELGA BI-RADS® Codierung -->
    <hl7:entry>
      <hl7:observation classCode="OBS" moodCode="EVN">
        <!-- Mammography Observation -->
        <hl7:templateId root="1.2.40.0.34.11.5.3.1"/>        <hl7:code code="36625-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Breast Mammogram"/>        <hl7:text>
          <hl7:reference value="#birads"/>        </hl7:text>        <hl7:statusCode code="completed"/>        <hl7:effectiveTime value="20110830103000+02"/>        <hl7:value xsi:type="CD" code="MA.II.A.5.4A" codeSystem="1.2.40.0.34.5.49" codeSystemName="ELGA_MammogramAssessment"/>      </hl7:observation>    </hl7:entry>  </hl7:section></hl7:ClinicalDocument>
ItemDTKardKonfBeschreibungLabel
hl7:section
(Befund)
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.pnghl7:templateId
II1 … 1R(Befund)
Treeblank.pngTreetree.png@root
uid1 … 1F1.2.40.0.34.11.5.2.9
Treetree.pnghl7:code
CE1 … 1M(Befund)
Treeblank.pngTreetree.png@code
CONF1 … 1F18782-3
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1FStudy observation
Treetree.pnghl7:title
ST1 … 1M(Befund)
 CONF
Elementinhalt muss "Befund" sein
Treetree.pnghl7:text
SD.TEXT1 … 1M
Befundtext sollte in Abschnitte (<paragraph>) gegliedert sein. Vorgegebene Struktur für Mammographie: Klassifikationen nach BI-RADS® oder nach ACR Index MÜSSEN im Textteil als Tabelle enthalten sein.
Empfohlen wird die Angabe der BI-RADS® Klassen in arabischen Ziffern.
(Befund)
Treetree.pnghl7:entry
Beinhaltet 1.2.40.0.34.11.5.3.2 Kodierung des Befundtextes (DYNAMIC)(Befund)
Treeblank.png wo [hl7:observation [hl7:code [(@code = '121071' and @codeSystem = '1.2.840.10008.2.16.4')]]]
Treetree.pnghl7:entry
Beinhaltet 1.2.40.0.34.11.5.3.1 BI-RADS® Klassifikation (DYNAMIC)(Befund)
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