1.2.40.0.34.6.0.11.3.197

Weitere Informationen sind zusammengefasst im Hilfe-Beitrag Templates.

1 Template komplexe_bewertung_entry

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.

1.1 Aktuelle Version

Id	1.2.40.0.34.6.0.11.3.197	Gültigkeit ab	2026‑08‑03 11:52:41
Status	Entwurf	Versions-Label
Name	komplexe_bewertung_entry	Bezeichnung	Komplexe 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.
Kontext	Elternknoten des Template-Element mit Id 1.2.40.0.34.6.0.11.3.197
Label	atpatho_entry_KomplexeBewertungEntry
Klassifikation	CDA Entry Level Template
Offen/Geschlossen	Geschlossen (nur definierte Elemente sind erlaubt)
Benutzt	Benutzt 3 Templates Benutzt als Name Version 1.2.40.0.34.6.0.11.9.1 Inklusion Narrative Text Reference (1.0.1+20210512) 2021‑05‑06 09:38:20 1.2.40.0.34.6.0.11.9.24 Containment Performer - Laboratory (1.0.0+20211213) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.4.2 Containment IHE Comment Entry (2014) 2013‑12‑20
Beziehung	Spezialisierung: 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>
Item DT Kard Konf Beschreibung Label hl7:observation 0 … * R atpa...ntry @classCode cs 1 … 1 F OBS @moodCode cs 1 … 1 F EVN @negationInd bl 0 … 1   hl7:templateId II 1 … 1 M atpa...ntry @root uid 1 … 1 F 1.2.40.0.34.6.0.11.3.197 hl7:id II 0 … * R atpa...ntry hl7:code CE (extensible) 1 … 1 M Spezifikation welches Klassifikationssystem herangezogen wurde. TODO Value-Set erstellen atpa...ntry Eingefügt 1 … 1 M von 1.2.40.0.34.6.0.11.9.1 Narrative Text Reference (2021‑05‑06 09:38:20) hl7:text ED 1 … 1 M atpa...ntry hl7:reference TEL 1 … 1 M Die 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 @value 1 … 1 R   Schematron assert role  error     test starts-with(@value,'#') or starts-with(@value,'http')     Meldung The @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.   hl7:statusCode CS (erforderlich) 1 … 1 M atpa...ntry @code CONF 1 … 1 F completed hl7:effectiveTime IVL_TS 1 … 1 M Date and time the observation has been made atpa...ntry hl7:value ST 1 … 1 M 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"/> hl7:performer II 0 … 1 R Beinhaltet 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. hl7:entryRelationship 0 … * R Annotation comment Beinhaltet 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (2013‑12‑20) atpa...ntry @typeCode cs 0 … 1 F COMP

1.2 Zusammenstellung aller Versionen dieses Templates

• 2026-08-03 11:52:41 (In Entwicklung)