1.2.40.0.34.6.0.11.3.197/static-2026-08-03T115241: Unterschied zwischen den Versionen

Aus HL7 Austria MediaWiki
Wechseln zu: Navigation, Suche
[unmarkierte Version][unmarkierte Version]
(Automatic ADBot page (c7162f15eae3335d68d11ffc226ea90a1c27f7ba))
 
(Automatic ADBot page (c7162f15eae3335d68d11ffc226ea90a1c27f7ba))
 
Zeile 1: Zeile 1:
−
<table xmlns="http://www.w3.org/1999/xhtml" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.2.40.0.34.6.0.11.3.197</td><th style="width: 20em; text-align: left;">Gültigkeit ab</th><td style="text-align: left;">2026‑08‑03 11:52:41<div>Andere Versionen mit dieser Id:<ul><li>[[File:Kblank.png|14px]] APObservationEntry vom  2014‑05‑14 17:09:54</li></ul></div></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] Entwurf</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;">2.0</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">APObservationEntry</td><th style="width: 20em; text-align: left;">Bezeichnung</th><td style="text-align: left;">AP Observation Entry</td></tr><tr style="vertical-align: top;"><td style="text-align: left;" colspan="4"><table id="templateDescTable" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Beschreibung</td></tr><tr><td><div>
+
<table xmlns="http://www.w3.org/1999/xhtml" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.2.40.0.34.6.0.11.3.197</td><th style="width: 20em; text-align: left;">Gültigkeit ab</th><td style="text-align: left;">2026‑08‑03 11:52:41</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] Entwurf</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;"></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">komplexe_bewertung_entry</td><th style="width: 20em; text-align: left;">Bezeichnung</th><td style="text-align: left;">Komplexe Bewertung Entry</td></tr><tr style="vertical-align: top;"><td style="text-align: left;" colspan="4"><table id="templateDescTable" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Beschreibung</td></tr><tr><td><div>
 
<span class="xforms-group" id="xf-156">
 
<span class="xforms-group" id="xf-156">
 
<span class="fr-accordion-lnf xforms-group" id="xf-178$fr-accordion-group">
 
<span class="fr-accordion-lnf xforms-group" id="xf-178$fr-accordion-group">
Zeile 7: Zeile 7:
 
</span>
 
</span>
 
</span>
 
</span>
−
</span>  
+
</span>          
−
<p style="margin: 0px 0px 6px;">This Content Module is usable within a Problem Organizer.</p>  
+
<p style="margin: 0px 0px 6px;">This Content Module is usable within a Problem Organizer.</p>          
−
<p style="margin: 0px 0px 6px;">The “AP Observation” generic template is usable for all AP observations, including ancillary techniques.</p>  
+
<p style="margin: 0px 0px 6px;">The “AP Observation” generic template is usable for all AP observations, including ancillary techniques.</p>          
−
<p style="margin: 0px 0px 3px;">Each specific AP observation is associated to a specific template, child of the “AP Observation” generic template. This specific child template has exactly the same structure as the generic one, and brings only a number of vocabulary constraints related to the type of observation and to the type of organ source of the specimen observed: </p>  
+
<p style="margin: 0px 0px 3px;">Each specific AP observation is associated to a specific template, child of the “AP Observation” generic template. This specific child template has exactly the same structure as the generic one, and brings only a number of vocabulary constraints related to the type of observation and to the type of organ source of the specimen observed: </p>          
 
<ul>
 
<ul>
 
<li style="margin: 0px 0px 3px;">The code for the specific observation, defined as a value set bound to the observation/code element, containing a single triplet (code, codeSystem, displayName) representing this specific observation.</li>
 
<li style="margin: 0px 0px 3px;">The code for the specific observation, defined as a value set bound to the observation/code element, containing a single triplet (code, codeSystem, displayName) representing this specific observation.</li>
Zeile 16: Zeile 16:
 
<li style="margin: 0px 0px 6px;">The domain of values for this observation in case these values are coded. This domain of coded values is defined as a value set bound to the observation/value element, containing as many triplets (code, codeSystem, displayName) as there are admissible result values for this specific observation performed on a specimen taken from this specific
 
<li style="margin: 0px 0px 6px;">The domain of values for this observation in case these values are coded. This domain of coded values is defined as a value set bound to the observation/value element, containing as many triplets (code, codeSystem, displayName) as there are admissible result values for this specific observation performed on a specimen taken from this specific
 
organ.</li>
 
organ.</li>
−
</ul>  
+
</ul>          
−
<p style="margin: 0px 0px 6px;">An AP observation has a status and an effective time, may describe various participants (persons, devices, organizations), may have a number of additional properties (method, interpretation, text), and may contain embedded images, comments, and sub-observations, which are also AP observations.</p>  
+
<p style="margin: 0px 0px 6px;">An AP observation has a status and an effective time, may describe various participants (persons, devices, organizations), may have a number of additional properties (method, interpretation, text), and may contain embedded images, comments, and sub-observations, which are also AP observations.</p>          
 
<div>
 
<div>
 
<span style="letter-spacing: 0.0px">
 
<span style="letter-spacing: 0.0px">
 
<br />
 
<br />
 
</span>
 
</span>
−
</div>   
+
</div>
−
<span lang="EN-US" style
 

Aktuelle Version vom 26. August 2026, 23:22 Uhr

Id1.2.40.0.34.6.0.11.3.197Gültigkeit ab2026‑08‑03 11:52:41
StatusKyellow.png EntwurfVersions-Label
Namekomplexe_bewertung_entryBezeichnungKomplexe Bewertung Entry
Beschreibung

Template CDA Observation (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF).

This Content Module is usable within a Problem Organizer.

The “AP Observation” generic template is usable for all AP observations, including ancillary techniques.

Each specific AP observation is associated to a specific template, child of the “AP Observation” generic template. This specific child template has exactly the same structure as the generic one, and brings only a number of vocabulary constraints related to the type of observation and to the type of organ source of the specimen observed: 

  • The code for the specific observation, defined as a value set bound to the observation/code element, containing a single triplet (code, codeSystem, displayName) representing this specific observation.
  • The cardinalities and default type for the observation/value element carrying the results of this observation.
  • The domain of values for this observation in case these values are coded. This domain of coded values is defined as a value set bound to the observation/value element, containing as many triplets (code, codeSystem, displayName) as there are admissible result values for this specific observation performed on a specimen taken from this specific organ.

An AP observation has a status and an effective time, may describe various participants (persons, devices, organizations), may have a number of additional properties (method, interpretation, text), and may contain embedded images, comments, and sub-observations, which are also AP observations.

KontextElternknoten des Template-Element mit Id 1.2.40.0.34.6.0.11.3.197
Labelatpatho_entry_KomplexeBewertungEntry
KlassifikationCDA Entry Level Template
Offen/GeschlossenGeschlossen (nur definierte Elemente sind erlaubt)
Benutzt
Benutzt 3 Templates
Benutzt als NameVersion
1.2.40.0.34.6.0.11.9.1InklusionKgreen.png Narrative Text Reference (1.0.1+20210512)2021‑05‑06 09:38:20
1.2.40.0.34.6.0.11.9.24ContainmentKgreen.png Performer - Laboratory (1.0.0+20211213)DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.2ContainmentKgreen.png IHE Comment Entry (2014)2013‑12‑20
BeziehungSpezialisierung: Template 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (2014‑05‑14 17:09:54)
ref
psr-

Spezialisierung: Template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
Beispiel
Observation example for use case #1, estrogen receptor
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.4.9"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_ER"/>  <code code="16112-5" codeSystem="2.16.840.1.113883.6.1" displayName="Estrogen receptor [Interpretation] in Tissue"/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="201001041405-0500"/>  </effectiveTime>  <value xsi:type="CD" code="416053008" displayName="Estrogen receptor positive tumor (disorder)" codeSystem="2.16.840.1.113883.6.96"/>  <methodCode code="0107" displayName="Microscopy" codeSystem="2.16.840.1.113883.5.84"/>  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'CDA Performer IHE (Body)' (dynamic) -->
  </performer>  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) -->
  </author>  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Body) APSR2' (dynamic) -->
  </informant>  <participant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (dynamic) -->
  </participant>  <entryRelationship xsi:type="" typeCode="COMP">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' -->
  </entryRelationship>  <entryRelationship xsi:type="" typeCode="COMP">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' -->
  </entryRelationship>  <entryRelationship xsi:type="" typeCode="COMP">
    <!-- template 2.16.840.1.113883.10.12.307 'CDA RegionOfInterest' -->
  </entryRelationship>  <specimen typeCode="SPC">
    <specimenRole classCode="SPEC">
      <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008_slide_A1_ER"/>    </specimenRole>  </specimen>  <reference>
    <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (dynamic) -->
  </reference></observation>
ItemDTKardKonfBeschreibungLabel
hl7:observation
0 … *Ratpa...ntry
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 
Treetree.pnghl7:templateId
II1 … 1Matpa...ntry
Treeblank.pngTreetree.png@root
uid1 … 1F1.2.40.0.34.6.0.11.3.197
Treetree.pnghl7:id
II0 … *Ratpa...ntry
Treetree.pnghl7:code
CE (extensible)1 … 1M

Spezifikation welches Klassifikationssystem herangezogen wurde.

TODO Value-Set erstellen

atpa...ntry
Eingefügt1 … 1M von 1.2.40.0.34.6.0.11.9.1 Narrative Text Reference (2021‑05‑06 09:38:20)
Treetree.pnghl7:text
ED1 … 1Matpa...ntry
Treeblank.pngTreetree.pnghl7:reference
TEL1 … 1MDie Referenz auf den entsprechenden Text im menschenlesbaren Teil muss durch Bezugnahme auf den Inhalt[@ID] angegeben werden: reference[@value='#xxx'].
Die Referenz ist mit einem ID-Attribut anzugeben, dieses Element DARF NUR den Textinhalt des codierten Inhalts mit Zusatzinformationen umschließen.

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


atpa...ntry
Treeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
 Schematron assertrole error 
 teststarts-with(@value,'#') or starts-with(@value,'http') 
 MeldungThe @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content'-element, or begin with the 'http' or 'https' url-scheme. 
Treetree.pnghl7:statusCode
CS (erforderlich)1 … 1Matpa...ntry
Treeblank.pngTreetree.png@code
CONF1 … 1Fcompleted
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1MEN-US.png Date and time the observation has been madeatpa...ntry
Treetree.pnghl7:value
ST1 … 1MEN-US.png Ergebnis des verwendeten Klassifikationssystems als Text.
atpa...ntry
 Beispiel
for observation on tumor type
<value code="8500/3" codeSystem="2.16.840.1.113883.6.43.1" codeSystemName="ICD-O-3" displayName="Invasive carcinoma of the breast, no special type"/>
Treetree.pnghl7:performer
II0 … 1RBeinhaltet 1.2.40.0.34.6.0.11.9.24 Performer - Laboratory (DYNAMIC)atpa...ntry
 Constraint

Wurde der Befund nur von einem Institut 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).

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.

Treetree.pnghl7:entryRelationship
0 … *REN-US.png Annotation comment







Beinhaltet 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (2013‑12‑20)		atpa...ntry
Treeblank.pngTreetree.png@typeCode
cs0 … 1FCOMP
Abgerufen von „https://wiki.hl7.at/index.php?title=1.2.40.0.34.6.0.11.3.197/static-2026-08-03T115241&oldid=177021“