1.2.40.0.34.6.0.11.3.25/static-2019-05-07T125927: Unterschied zwischen den Versionen

[unmarkierte Version]

Version vom 24. Juni 2021, 22:57 Uhr

Id

1.2.40.0.34.6.0.11.3.25

ref

at-cda-bbr-

Gültigkeit

2019‑05‑07 12:59:27

Status

Entwurf

Versions-Label

1.0.0

Name

atcdabbr_entry_LaboratoryReportDataProcessing

Bezeichnung

Laboratory Report Data Processing Entry

Beschreibung

Der "Laboratory Report Data Processing Entry" repräsentiert die CDA Level 3 Codierung der Ergebnisse eines Befundbereiches. Im zugehörigen "section/text" befinden sich diese Ergebnisse in CDA Level 2. Das "entry"-Element MUSS mit dem Attribut @typeCode="DRIV" versehen werden, um anzuzeigen, dass der CDA Level 2 vollständig aus dem CDA Level 3 erzeugt werden kann. Das "entry"-Element enthält genau ein "act"-Subelement, das gemäß IHE PaLM TF3 "Specimen Act" genannt wird (nicht zu verwechseln mit den Templates "Probeninformation (Specimen Section)", "Probeninformation (Specimen Entry)", "Specimen Collection" oder "Specimen Received").

Innerhalb des "Specimen Act" werden alle weiteren Elemente (Untersuchungsmaterial, Befundgruppen, Analysen, etc.) codiert. Der "Specimen Act" MUSS zumindest ein weiteres Element beinhalten.

Kontext

Geschwisterknoten des Template-Element mit Id 1.2.40.0.34.6.0.11.3.25

Klassifikation

CDA Entry Level Template

Offen/Geschlossen

Geschlossen (nur definierte Elemente sind erlaubt)

Benutzt

Benutzt 8 Templates

Benutzt	als	Name	Version
1.2.40.0.34.6.0.11.9.24	Containment	Performer - Laboratory (1.0.0)	DYNAMIC
1.2.40.0.34.6.0.11.3.161	Containment	Specimen Collection (1.0.0)	DYNAMIC
1.2.40.0.34.6.0.11.3.165	Containment	Notification Organizer (1.0.0)	DYNAMIC
1.2.40.0.34.6.0.11.3.167	Containment	Laboratory Isolate Organizer (1.0.0)	DYNAMIC
1.2.40.0.34.6.0.11.3.26	Containment	Laboratory Battery Organizer (1.0.0)	DYNAMIC
1.2.40.0.34.6.0.11.3.27	Containment	Laboratory Observation (1.1.0)	DYNAMIC
1.2.40.0.34.6.0.11.3.19	Containment	Eingebettetes Objekt Entry (1.0.0+20210219)	DYNAMIC
1.2.40.0.34.6.0.11.3.11	Containment	Comment Entry (1.0.0+20210219)	DYNAMIC

Beziehung

Spezialisierung: Template 1.3.6.1.4.1.19376.1.3.1 BC Laboratory Report Data Processing Entry (DYNAMIC)

ref

bccdapilot-

Beispiel

Item

DT

Kard

Konf

Beschreibung

Label

hl7:templateId

II

1 … 1

M

Laboratory Report Data Processing Entry

(atc...ing)

@root

uid

1 … 1

F

1.2.40.0.34.6.0.11.3.25

hl7:templateId

II

1 … 1

M

IHE PalM TF3 Rev.10, 6.3.4.2 Laboratory Report Data Processing Entry

(atc...ing)

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.3.1

hl7:act

1 … 1

M

Specimen Act

(atc...ing)

@classCode

cs

1 … 1

F

ACT

@moodCode

cs

1 … 1

F

EVN

hl7:code

CD

1 … 1

M

Der Code für den Befundbereich MUSS dem der übergeordneten "Laboratory Specialty Section" entsprechen.

(atc...ing)

@code

cs

1 … 1

R

@codeSystem

oid

1 … 1

R

@codeSystemName

st

0 … 1

@displayName

st

1 … 1

R

Schematron assert

role

error

test

@code=../../../hl7:code/@code and @codeSystem=../../../hl7:code/@codeSystem

Meldung

Die hier angegebenen @code und @codeSystem MÜSSEN mit den Werten der übergeordneten Section ident sein.

hl7:statusCode

CS

1 … 1

M

Der "statusCode" kann folgende Werte annehmen:

completed: zu verwenden, wenn alle erwarteten Analyseergebnisse für diesen Befundbereich abgeschlossen sind.
aborted: zu verwenden, wenn zumindest ein Analyseergebnis für diesen Befundbereich nicht abgeschlossen werden konnte (abgebrochen wurde).

Der Wert "active" DARF NICHT verwendet werden. Befunde, die noch nicht abgeschlossen sind, sind mit /ClinicalDocument/sdtc:statusCode[@code="active"] zu codieren. Siehe dazu auch Template "Laboratory Observation", wo ein Beispiel zu einer noch nicht abgeschlossenen Analyse ("Wert folgt") angegeben ist.

(atc...ing)

CONF

@code muss "completed" sein

oder

@code muss "aborted" sein

hl7:performer

0 … *

C

Erbringer der Gesundheitsdienstleistung (Labor mit seinem Leiter).

Beinhaltet 1.2.40.0.34.6.0.11.9.24 Performer - Laboratory (DYNAMIC)

(atc...ing)

Constraint

Wurde der Befund nur von einem Labor erstellt, MUSS dieses in "/ClinicalDocument/documentationOf[1]/serviceEvent/performer" dokumentiert werden.

Sind mehrere Labors an der Erstellung beteiligt, MUSS das Labor im "structuredBody" entweder auf "entry"-Ebene oder im Rahmen eines "organizer"-Elementes oder direkt bei der Analyse ("observation"-Element) angegeben werden. Angaben in tieferen Ebenen (z.B. "observation"-Ebene) überschreiben solche auf höheren Ebenen (z.B. "organizer"-Ebene).

Constraint

Für den Fall, dass Analysen von einem externen Labor durchgeführt wurden, MUSS assignedEntity/code mit @code="E", @codeSystem="2.16.840.1.113883.2.16.1.4.9", @codeSystemName="HL7.at.Laborkennzeichnung" und @displayName="EXTERN" angegeben werden.

Auswahl

1 … *

Elemente in der Auswahl:

hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.161 Specimen Collection (DYNAMIC)
hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.165 Notification Organizer (DYNAMIC)
hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.167 Laboratory Isolate Organizer (DYNAMIC)
hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.26 Laboratory Battery Organizer (DYNAMIC)
hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.27 Laboratory Observation (DYNAMIC)
hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.19 Eingebettetes Objekt Entry (DYNAMIC)
hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.11 Comment Entry (DYNAMIC)

hl7:entryRelationship

0 … *

C

Probeninformation

Informationen zur CDA Level 2 Darstellung können der Section "Probeninformation (Specimen Section)" entnommen werden.

Beinhaltet 1.2.40.0.34.6.0.11.3.161 Specimen Collection (DYNAMIC)

(atc...ing)

@typeCode

cs

1 … 1

F

COMP

@contextConductionInd

cs

0 … 1

F

true

Constraint

Die Verwendung von "Specimen Collection" innerhalb des "Laboratory Report Data Processing Entry" ist NUR dann zulässig, wenn NUR EIN Befundbereich ("Laboratory Specialty Section") im gesamten Befund vorkommt und die "Specimen Collection" nicht schon als Teil der Section "Probeninformation (Specimen Section)" codiert wurde.

hl7:entryRelationship

0 … 1

Sammlung von wichtigen Erregern ("Notifiable Condition")

Beinhaltet 1.2.40.0.34.6.0.11.3.165 Notification Organizer (DYNAMIC)

(atc...ing)

@typeCode

cs

1 … 1

F

COMP

@contextConductionInd

cs

0 … 1

F

true

hl7:entryRelationship

0 … *

Codierung von kulturellen Erregernachweisen.

Beinhaltet 1.2.40.0.34.6.0.11.3.167 Laboratory Isolate Organizer (DYNAMIC)

(atc...ing)

@typeCode

cs

1 … 1

F

COMP

@contextConductionInd

cs

0 … 1

F

true

hl7:entryRelationship

0 … *

Codierung einer Befundgruppe innerhalb eines Befundbereiches.

Beinhaltet 1.2.40.0.34.6.0.11.3.26 Laboratory Battery Organizer (DYNAMIC)

(atc...ing)

@typeCode

cs

1 … 1

F

COMP

@contextConductionInd

cs

0 … 1

F

true

hl7:entryRelationship

0 … *

Codierung von Analyseergebnissen, die direkt einem Befundbereich ("Laboratory Specialty Section") zugeordnet werden. Das kann z.B. im Rahmen eines Mikrobiologiebefundes erforderlich sein, in dem prinzpiell eine weitere Gliederung in Befundgruppen ("Laboratory Battery Organizer") wegfällt.

Beinhaltet 1.2.40.0.34.6.0.11.3.27 Laboratory Observation (DYNAMIC)

(atc...ing)

@typeCode

cs

1 … 1

F

COMP

@contextConductionInd

cs

0 … 1

F

true

hl7:entryRelationship

0 … *

Beinhaltet 1.2.40.0.34.6.0.11.3.19 Eingebettetes Objekt Entry (DYNAMIC)

(atc...ing)

@typeCode

cs

1 … 1

F

COMP

@contextConductionInd

cs

0 … 1

F

true

hl7:entryRelationship

0 … *

Codierung des Kommentars für einen gesamten Befundbereich.

Beinhaltet 1.2.40.0.34.6.0.11.3.11 Comment Entry (DYNAMIC)

(atc...ing)

@typeCode

cs

1 … 1

F

COMP

@contextConductionInd

cs

0 … 1

F

true

Beispiel

Kommentar zum Befundbereich

<section>
  <templateId root="1.2.40.0.34.6.0.11.2.102"/>  <id extension="P-body" root="2.16.840.1.113883.3.933.1.1"/>  <code code="300" codeSystem="1.2.40.0.34.5.11" codeSystemName="ELGA_LaborparameterErgaenzung" displayName="Hämatologie"/>  <title>Hämatologie</title>  
  <text>
    
    
    
    
    <table>
      <thead>
        <tr>
          <th>Kommentar zur Hämatologie</th>        </tr>      </thead>      <tbody>
        <tr>
          <td>
            <paragraph>
              <content ID="haematologyComment1">Das ist ein Kommentar zum Befundbereich "Hämatologie".</content>            </paragraph>          </td>        </tr>      </tbody>    </table>  </text>  
  <entry typeCode="DRIV">
    <templateId root="1.2.40.0.34.6.0.11.3.25"/>    <templateId root="1.3.6.1.4.1.19376.1.3.1"/>    <act classCode="ACT" moodCode="EVN">
      <code code="300" codeSystem="1.2.40.0.34.5.11" codeSystemName="ELGA_LaborparameterErgaenzung" displayName="Hämatologie"/>      <statusCode code="completed"/>      
      
      
      
      <entryRelationship typeCode="COMP">
        <act classCode="ACT" moodCode="EVN">
          <templateId root="1.2.40.0.34.6.0.11.3.25"/>          <templateId root="2.16.840.1.113883.10.20.1.40"/>          <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.2"/>          <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation Comment"/>          <text>
            <reference value="#haematologyComment1"/>          </text>          <statusCode code="completed"/>        </act>      </entryRelationship>    </act>  </entry></section>

@@ Zeile 3: / Zeile 3: @@
 <li><b>aborted:</b> zu verwenden, wenn zumindest ein Analyseergebnis für diesen Befundbereich nicht abgeschlossen werden konnte (abgebrochen wurde).</li>
 </ul>Der Wert "active" <b>DARF NICHT</b> verwendet werden. Befunde, die noch nicht abgeschlossen sind, sind mit /ClinicalDocument/sdtc:statusCode[@code="active"] zu codieren. Siehe dazu auch Template "Laboratory Observation", wo ein Beispiel zu einer noch nicht abgeschlossenen Analyse ("Wert folgt") angegeben ist. </td><td style="background-color: #FFEEEE;"><span title="">(atc...ing)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>@code muss "completed" sein</td></tr><tr style="vertical-align: top;"><td>oder</td></tr><tr style="vertical-align: top;"><td>@code muss "aborted" sein</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:performer<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>C</strong></span></td><td>Erbringer der Gesundheitsdienstleistung (Labor mit seinem Leiter).<br />
-<br />Beinhaltet 1.2.40.0.34.6.0.11.9.24 <i>Performer - Laboratory</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(atc...ing)</span></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4">Wurde der Befund nur von <b>einem</b> Labor erstellt, <b>MUSS</b> dieses in "/ClinicalDocument/documentationOf[1]/serviceEvent/performer" dokumentiert werden.<br /><br />Sind <b>mehrere</b> Labors an der Erstellung beteiligt, <b>MUSS</b> das Labor im "structuredBody" entweder auf <b>"entry"</b>-Ebene oder im Rahmen eines <b>"organizer"</b>-Elementes oder direkt bei der Analyse (<b>"observation"</b>-Element) angegeben werden. Angaben in tieferen Ebenen (z.B. "observation"-Ebene) überschreiben solche auf höheren Ebenen (z.B. "organizer"-Ebene). </td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"> Für den Fall, dass Analysen von einem externen Labor durchgeführt wurden, <b>MUSS</b> assignedEntity/code mit @code="E", @codeSystem="2.16.840.1.113883.2.16.1.4.9", @codeSystemName="HL7.at.Laborkennzeichnung" und @displayName="EXTERN" angegeben werden. </td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td><span style="color: black;"><strong>1 … *</strong></span></td><td></td><td colspan="2">Elemente in der Auswahl:<ul><li>hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.161 <i>Specimen Collection</i> (DYNAMIC)</li><li>hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.165 <i>Notification Organizer</i> (DYNAMIC)</li><li>hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.167 <i>Laboratory Isolate Organizer</i> (DYNAMIC)</li><li>hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.26 <i>Laboratory Battery Organizer</i> (DYNAMIC)</li><li>hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.27 <i>Laboratory Observation</i> (DYNAMIC)</li><li>hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.19 <i>Eingebettetes Objekt Entry</i> (DYNAMIC)</li><li>hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.11 <i>Comment Entry</i> (DYNAMIC)</li></ul></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:entryRelationship<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Probeninformation<br />
+<br />Beinhaltet 1.2.40.0.34.6.0.11.9.24 <i>Performer - Laboratory</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(atc...ing)</span></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4">Wurde der Befund nur von <b>einem</b> Labor erstellt, <b>MUSS</b> dieses in "/ClinicalDocument/documentationOf[1]/serviceEvent/performer" dokumentiert werden.<br /><br />Sind <b>mehrere</b> Labors an der Erstellung beteiligt, <b>MUSS</b> das Labor im "structuredBody" entweder auf <b>"entry"</b>-Ebene oder im Rahmen eines <b>"organizer"</b>-Elementes oder direkt bei der Analyse (<b>"observation"</b>-Element) angegeben werden. Angaben in tieferen Ebenen (z.B. "observation"-Ebene) überschreiben solche auf höheren Ebenen (z.B. "organizer"-Ebene). </td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"> Für den Fall, dass Analysen von einem externen Labor durchgeführt wurden, <b>MUSS</b> assignedEntity/code mit @code="E", @codeSystem="2.16.840.1.113883.2.16.1.4.9", @codeSystemName="HL7.at.Laborkennzeichnung" und @displayName="EXTERN" angegeben werden. </td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td><span style="color: black;"><strong>1 … *</strong></span></td><td></td><td colspan="2">Elemente in der Auswahl:<ul><li>hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.161 <i>Specimen Collection</i> (DYNAMIC)</li><li>hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.165 <i>Notification Organizer</i> (DYNAMIC)</li><li>hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.167 <i>Laboratory Isolate Organizer</i> (DYNAMIC)</li><li>hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.26 <i>Laboratory Battery Organizer</i> (DYNAMIC)</li><li>hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.27 <i>Laboratory Observation</i> (DYNAMIC)</li><li>hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.19 <i>Eingebettetes Objekt Entry</i> (DYNAMIC)</li><li>hl7:entryRelationship welches enthält Template 1.2.40.0.34.6.0.11.3.11 <i>Comment Entry</i> (DYNAMIC)</li></ul></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:entryRelationship<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>C</strong></span></td><td>Probeninformation<br /><br /> Informationen zur CDA Level 2 Darstellung können der Section "Probeninformation (Specimen Section)" entnommen werden.<br />
 <br />Beinhaltet 1.2.40.0.34.6.0.11.3.161 <i>Specimen Collection</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(atc...ing)</span></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@typeCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@context&#8203;Conduction&#8203;Ind<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">true</td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4">Die Verwendung von "Specimen Collection" innerhalb des "Laboratory Report Data Processing Entry" ist <b>NUR</b> dann zulässig, wenn <b>NUR EIN</b> Befundbereich ("Laboratory Specialty Section") im gesamten Befund vorkommt und die "Specimen Collection" nicht schon als Teil der Section "Probeninformation (Specimen Section)" codiert wurde.</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:entryRelationship<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Sammlung von wichtigen Erregern ("Notifiable Condition")<br />
 <br />Beinhaltet 1.2.40.0.34.6.0.11.3.165 <i>Notification Organizer</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(atc...ing)</span></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@typeCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@context&#8203;Conduction&#8203;Ind<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">true</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:entryRelationship<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Codierung von kulturellen Erregernachweisen.<br />
@@ Zeile 10: / Zeile 10: @@
 <br />Beinhaltet 1.2.40.0.34.6.0.11.3.27 <i>Laboratory Observation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(atc...ing)</span></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@typeCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@context&#8203;Conduction&#8203;Ind<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">true</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:entryRelationship<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.3.19 <i>Eingebettetes Objekt Entry</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(atc...ing)</span></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@typeCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@context&#8203;Conduction&#8203;Ind<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">true</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:entryRelationship<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Codierung des Kommentars für einen gesamten Befundbereich.<br />
 <br />Beinhaltet 1.2.40.0.34.6.0.11.3.11 <i>Comment Entry</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(atc...ing)</span></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@typeCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@context&#8203;Conduction&#8203;Ind<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">true</td></tr><tr class="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Beispiel</td><td colspan="4" class="explabelgreen"><div>Kommentar zum Befundbereich</div><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;"><span style="color:green">&lt;!-- Befundbereich --&gt;<br /></span></span><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">1.2.40.0.34.6.0.11.2.102</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">id</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">P-body</span><span class="ppsign">"</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.3.933.1.1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">300</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.5.11</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">ELGA_LaborparameterErgaenzung</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Hämatologie</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">Hämatologie</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;!-- CDA Level 2 --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- ... --&gt;<br /></span></span><span style="display: block;">    <span style="color:green">&lt;!-- Inhalte von meldepflichtigen Erkrankungen, Befundgruppen, etc. --&gt;<br /></span></span><span style="display: block;">    <span style="color:green">&lt;!-- ... --&gt;<br /></span></span><span style="display: block;">    <span style="color:green">&lt;!-- Kommentar zum Befundbereich als letztes Element in "section/text" --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</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="ppelement">thead</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</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="ppelement">th</span><span class="ppsign">&gt;</span><span class="pptext">Kommentar zur Hämatologie</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">th</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">tr</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace"></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="ppelement">tbody</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</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="ppelement">td</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</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="ppelement">content</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">haematologyComment1</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">Das ist ein Kommentar zum Befundbereich "Hämatologie".</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">content</span><span class="ppsign">&gt;</span></span>            <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">paragraph</span><span class="ppsign">&gt;</span></span>          <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">tr</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">tbody</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">table</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- CDA Level 3 --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entry</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">DRIV</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.6.0.11.3.25</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.3.1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">act</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">ACT</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">300</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.5.11</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">ELGA_LaborparameterErgaenzung</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Hämatologie</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">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">completed</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">      <span style="color:green">&lt;!-- ... --&gt;<br /></span></span><span style="display: block;">      <span style="color:green">&lt;!-- Codierung von meldepflichtigen Erkrankungen, Befundgruppen, Analysen, etc. --&gt;<br /></span></span><span style="display: block;">      <span style="color:green">&lt;!-- ... --&gt;<br /></span></span><span style="display: block;">      <span style="color:green">&lt;!-- Codierung des Kommentars zum Befundbereich --&gt;<br /></span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppelement">act</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">ACT</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.6.0.11.3.25</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.10.20.1.40</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.5.3.1.4.2</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="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">48767-8</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">LOINC</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Annotation Comment</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#haematologyComment1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>          <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">completed</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">act</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">act</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entry</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></span></td></tr></table></td></tr></table>
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1.2.40.0.34.6.0.11.3.25/static-2019-05-07T125927: Unterschied zwischen den Versionen

Version vom 24. Juni 2021, 22:57 Uhr

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