1.2.40.0.34.11.14.2.6/static-2018-10-09T133507

Id 1.2.40.0.34.11.14.2.6 Gültigkeit 2018‑10‑09 13:35:07

Status Entwurf Versions-Label

Name Anamnese Anzeigename Anamnese

Beschreibung

Die Anamnese enthält die professionelle Erfragung von potenziell medizinisch relevanten Informationen durch Fachpersonal (z.B. einen Arzt) basierend auf den Aussagen des Patienten (Eigenanamnese) oder einer dritten Person (Fremdanamnese) zum aktuellen Konsultationsanlass.

Die Anamnese kann sich in mehrere Abschnitte gliedern, z.B.

biografische Anamnese, allgemeine Anamnese,

       
           vegetative Anamnese,

       
           Ernährungsanamnese,

       
           Suchtanamnese,

       
           psychosoziale Anamnese,

       
           Sexualanamnese,

       
           Familienanamnese

       
           Sozialanamnese

       
           Fachspezifische Anamnese

   Wenn eine höhere Strukturierung notwendig ist, können die angegebenen Subsektionen eingefügt werden. 

       

   
   
       Fachspezifische Erweiterung: 
   Fachspezifisch notwendige strukturierte oder codierte Daten müssen in einer separat definierten offiziellen Untersektion eingefügt werden.

Kontext Elternknoten des Template-Element mit Id 1.2.40.0.34.11.14.2.6

Klassifikation CDA Section level template

Offen/Geschlossen Offen (auch andere als die definierten Elemente sind erlaubt)

Assoziiert mit

Assoziiert mit 1 Konzept

Id	Name	Datensatz
elgagab-dataelement-169	Anamnese	Datensatz

Benutzt

Benutzt 6 Templates

Benutzt	als	Name	Version
1.2.40.0.34.11.13.2.9	Containment	Schwangerschaften (0.1)	2017‑03‑11 18:04:25
1.2.40.0.34.11.13.2.4	Containment	Medizinische Geräte und Implantate (0.1)	2017‑02‑26 11:36:47
1.2.40.0.34.11.13.2.12	Containment	Beeinträchtigungen (0.1)	2017‑08‑04 12:10:57
1.2.40.0.34.11.13.2.7	Containment	Impfungen (0.1)	2017‑03‑11 18:38:41
1.2.40.0.34.11.13.2.8	Containment	Lebensstil (0.1)	2017‑03‑12 11:13:38
1.2.40.0.34.11.13.2.11	Containment	Willenserklärungen (0.1)	2017‑08‑04 11:56:28

Beispiel

Strukturbeispiel

<section> <templateId/> <code code="10164-2" codeSystem="2.16.840.1.113883.6.1" displayName="History of present illness"/> <title>Anamnese</title> <text/> <__CHOICE__ min="0" max="">  <component> <section> <templateId root="1.2.40.0.34.11.13.2.9"/> <id root="1.2.3.999" extension="--example only--"/> <code code="10162-6" codeSystem="2.16.840.1.113883.6.1"/> <title>Schwangerschaften</title> <text/> <author typeCode="AUT" contextControlCode="OP"> <time value="20181011124843"/> <assignedAuthor classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="--code--" codeSystem="1.2.40.0.34.10.6"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <__CHOICE__ min="1" max="1">  <assignedPerson>  <name>name</name> </assignedPerson>   <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE"> <manufacturerModelName>manufacturerModelName</manufacturerModelName> <softwareName>softwareName</softwareName> </assignedAuthoringDevice>  </__CHOICE__> <representedOrganization classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganization> </assignedAuthor>  </author> <informant typeCode="INF" contextControlCode="OP"> <__CHOICE__ min="1" max="1">  <assignedEntity classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="100" codeSystem="1.2.40.0.34.5.2" displayName="Ärztin/Arzt für Allgemeinmedizin"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <assignedPerson>  <name>name</name> </assignedPerson> <representedOrganisation classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganisation> </assignedEntity>   <relatedEntity classCode="PRS"> <code code="FAMMEMB" codeSystem="2.16.840.1.113883.5.111" displayName="Family Member"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <relatedPerson>  <name>name</name> </relatedPerson> </relatedEntity>  </__CHOICE__>  </informant> <entry typeCode="COMP"> <observation classCode="OBS" moodCode="EVN"> <templateId root="1.2.40.0.34.11.13.3.10"/> <code code="11449-6" codeSystem="2.16.840.1.113883.6.1" displayName="Pregnancy Status"/> <statusCode code="completed"/> <value value="--TODO--"/> <author typeCode="AUT" contextControlCode="OP"> <time value="20181011124843"/> <assignedAuthor classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="--code--" codeSystem="1.2.40.0.34.10.6"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <__CHOICE__ min="1" max="1">  <assignedPerson>  <name>name</name> </assignedPerson>   <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE"> <manufacturerModelName>manufacturerModelName</manufacturerModelName> <softwareName>softwareName</softwareName> </assignedAuthoringDevice>  </__CHOICE__> <representedOrganization classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganization> </assignedAuthor>  </author> <informant typeCode="INF" contextControlCode="OP"> <__CHOICE__ min="1" max="1">  <assignedEntity classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="100" codeSystem="1.2.40.0.34.5.2" displayName="Ärztin/Arzt für Allgemeinmedizin"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <assignedPerson>  <name>name</name> </assignedPerson> <representedOrganisation classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganisation> </assignedEntity>   <relatedEntity classCode="PRS"> <code code="FAMMEMB" codeSystem="2.16.840.1.113883.5.111" displayName="Family Member"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <relatedPerson>  <name>name</name> </relatedPerson> </relatedEntity>  </__CHOICE__>  </informant> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN"> <templateId root="1.2.40.0.34.11.13.3.24"/> <code/> <statusCode code="completed"/> <value value="--TODO--"/> <author typeCode="AUT" contextControlCode="OP"> <time value="20181011124843"/> <assignedAuthor classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="--code--" codeSystem="1.2.40.0.34.10.6"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <__CHOICE__ min="1" max="1">  <assignedPerson>  <name>name</name> </assignedPerson>   <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE"> <manufacturerModelName>manufacturerModelName</manufacturerModelName> <softwareName>softwareName</softwareName> </assignedAuthoringDevice>  </__CHOICE__> <representedOrganization classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganization> </assignedAuthor>  </author> <informant typeCode="INF" contextControlCode="OP"> <__CHOICE__ min="1" max="1">  <assignedEntity classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="100" codeSystem="1.2.40.0.34.5.2" displayName="Ärztin/Arzt für Allgemeinmedizin"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <assignedPerson>  <name>name</name> </assignedPerson> <representedOrganisation classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganisation> </assignedEntity>   <relatedEntity classCode="PRS"> <code code="FAMMEMB" codeSystem="2.16.840.1.113883.5.111" displayName="Family Member"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <relatedPerson>  <name>name</name> </relatedPerson> </relatedEntity>  </__CHOICE__>  </informant> <reference> <externalDocument classCode="DOC" moodCode="EVN"> <id root="1.2.3.999" extension="--example only--"/> <code/> <text/> </externalDocument>  </reference> </observation>  </entryRelationship> <reference> <externalDocument classCode="DOC" moodCode="EVN"> <id root="1.2.3.999" extension="--example only--"/> <code/> <text/> </externalDocument>  </reference> </observation>  </entry> <entry typeCode="COMP"> <observation classCode="OBS" moodCode="EVN"> <templateId root="1.2.40.0.34.11.13.3.23"/> <code/> <statusCode code="completed"/> <value value="--TODO--"/> <author typeCode="AUT" contextControlCode="OP"> <time value="20181011124843"/> <assignedAuthor classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="--code--" codeSystem="1.2.40.0.34.10.6"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <__CHOICE__ min="1" max="1">  <assignedPerson>  <name>name</name> </assignedPerson>   <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE"> <manufacturerModelName>manufacturerModelName</manufacturerModelName> <softwareName>softwareName</softwareName> </assignedAuthoringDevice>  </__CHOICE__> <representedOrganization classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganization> </assignedAuthor>  </author> <informant typeCode="INF" contextControlCode="OP"> <__CHOICE__ min="1" max="1">  <assignedEntity classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="100" codeSystem="1.2.40.0.34.5.2" displayName="Ärztin/Arzt für Allgemeinmedizin"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <assignedPerson>  <name>name</name> </assignedPerson> <representedOrganisation classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganisation> </assignedEntity>   <relatedEntity classCode="PRS"> <code code="FAMMEMB" codeSystem="2.16.840.1.113883.5.111" displayName="Family Member"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <relatedPerson>  <name>name</name> </relatedPerson> </relatedEntity>  </__CHOICE__>  </informant> <reference> <externalDocument classCode="DOC" moodCode="EVN"> <id root="1.2.3.999" extension="--example only--"/> <code/> <text/> </externalDocument>  </reference> </observation>  </entry> </section>  </component>   <component> <section> <templateId root="1.2.40.0.34.11.13.2.4"/> <id root="1.2.3.999" extension="--example only--"/> <code code="46264-8" codeSystem="2.16.840.1.113883.6.1"/> <title>Medizinische Geräte und Implantate</title> <text/> <author typeCode="AUT" contextControlCode="OP"> <time value="20181011124843"/> <assignedAuthor classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="--code--" codeSystem="1.2.40.0.34.10.6"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <__CHOICE__ min="1" max="1">  <assignedPerson>  <name>name</name> </assignedPerson>   <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE"> <manufacturerModelName>manufacturerModelName</manufacturerModelName> <softwareName>softwareName</softwareName> </assignedAuthoringDevice>  </__CHOICE__> <representedOrganization classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganization> </assignedAuthor>  </author> <informant typeCode="INF" contextControlCode="OP"> <__CHOICE__ min="1" max="1">  <assignedEntity classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="100" codeSystem="1.2.40.0.34.5.2" displayName="Ärztin/Arzt für Allgemeinmedizin"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <assignedPerson>  <name>name</name> </assignedPerson> <representedOrganisation classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganisation> </assignedEntity>   <relatedEntity classCode="PRS"> <code code="FAMMEMB" codeSystem="2.16.840.1.113883.5.111" displayName="Family Member"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <relatedPerson>  <name>name</name> </relatedPerson> </relatedEntity>  </__CHOICE__>  </informant> <entry typeCode="DRIV"> <supply classCode="SPLY" moodCode="EVN"> <templateId root="1.2.40.0.34.11.13.3.8"/> <id root="1.2.3.999" extension="--example only--"/> <__CHOICE__ min="0">  <code code="71861002" codeSystem="2.16.840.1.113883.6.96"/>    </__CHOICE__> <text> <reference value="--TODO--"/> </text> <effectiveTime> <low/> </effectiveTime> <author typeCode="AUT" contextControlCode="OP"> <time value="20181011124843"/> <assignedAuthor classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="--code--" codeSystem="1.2.40.0.34.10.6"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <__CHOICE__ min="1" max="1">  <assignedPerson>  <name>name</name> </assignedPerson>   <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE"> <manufacturerModelName>manufacturerModelName</manufacturerModelName> <softwareName>softwareName</softwareName> </assignedAuthoringDevice>  </__CHOICE__> <representedOrganization classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganization> </assignedAuthor>  </author> <informant typeCode="INF" contextControlCode="OP"> <__CHOICE__ min="1" max="1">  <assignedEntity classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="100" codeSystem="1.2.40.0.34.5.2" displayName="Ärztin/Arzt für Allgemeinmedizin"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <assignedPerson>  <name>name</name> </assignedPerson> <representedOrganisation classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganisation> </assignedEntity>   <relatedEntity classCode="PRS"> <code code="FAMMEMB" codeSystem="2.16.840.1.113883.5.111" displayName="Family Member"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <relatedPerson>  <name>name</name> </relatedPerson> </relatedEntity>  </__CHOICE__>  </informant> <participant typeCode="DEV"> <participantRole classCode="MANU"> <id/> <playingDevice classCode="DEV" determinerCode="INSTANCE"> <code> <originalText> <reference value="tel:+1-12345678"/> </originalText> <translation/> </code> </playingDevice> </participantRole> </participant> <reference> <externalDocument classCode="DOC" moodCode="EVN"> <id root="1.2.3.999" extension="--example only--"/> <code/> <text/> </externalDocument>  </reference> </supply>  </entry> </section>  </component>   <component> <section> <templateId root="1.2.40.0.34.11.13.2.12"/> <code code="47420-5" codeSystem="2.16.840.1.113883.6.1"/> <title>Beeinträchtigungen</title> <text/> <author typeCode="AUT" contextControlCode="OP"> <time value="20181011124843"/> <assignedAuthor classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="--code--" codeSystem="1.2.40.0.34.10.6"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <__CHOICE__ min="1" max="1">  <assignedPerson>  <name>name</name> </assignedPerson>   <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE"> <manufacturerModelName>manufacturerModelName</manufacturerModelName> <softwareName>softwareName</softwareName> </assignedAuthoringDevice>  </__CHOICE__> <representedOrganization classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganization> </assignedAuthor>  </author> <informant typeCode="INF" contextControlCode="OP"> <__CHOICE__ min="1" max="1">  <assignedEntity classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="100" codeSystem="1.2.40.0.34.5.2" displayName="Ärztin/Arzt für Allgemeinmedizin"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <assignedPerson>  <name>name</name> </assignedPerson> <representedOrganisation classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganisation> </assignedEntity>   <relatedEntity classCode="PRS"> <code code="FAMMEMB" codeSystem="2.16.840.1.113883.5.111" displayName="Family Member"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <relatedPerson>  <name>name</name> </relatedPerson> </relatedEntity>  </__CHOICE__>  </informant> </section>  </component>   <component> <section> <templateId root="1.2.40.0.34.11.13.2.7"/> <id root="1.2.3.999" extension="--example only--"/> <code code="11369-6 " codeSystem="2.16.840.1.113883.6.1"/> <title>Impfungen</title> <text/> <author typeCode="AUT" contextControlCode="OP"> <time value="20181011124843"/> <assignedAuthor classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="--code--" codeSystem="1.2.40.0.34.10.6"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <__CHOICE__ min="1" max="1">  <assignedPerson>  <name>name</name> </assignedPerson>   <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE"> <manufacturerModelName>manufacturerModelName</manufacturerModelName> <softwareName>softwareName</softwareName> </assignedAuthoringDevice>  </__CHOICE__> <representedOrganization classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganization> </assignedAuthor>  </author> <informant typeCode="INF" contextControlCode="OP"> <__CHOICE__ min="1" max="1">  <assignedEntity classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="100" codeSystem="1.2.40.0.34.5.2" displayName="Ärztin/Arzt für Allgemeinmedizin"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <assignedPerson>  <name>name</name> </assignedPerson> <representedOrganisation classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganisation> </assignedEntity>   <relatedEntity classCode="PRS"> <code code="FAMMEMB" codeSystem="2.16.840.1.113883.5.111" displayName="Family Member"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <relatedPerson>  <name>name</name> </relatedPerson> </relatedEntity>  </__CHOICE__>  </informant> <entry typeCode="DRIV"> <substanceAdministration classCode="SBADM" moodCode="EVN"> <templateId root="1.2.40.0.34.11.13.3.9"/> <id root="1.2.3.999" extension="--example only--"/> <code code="IMMUNIZ" codeSystem="2.16.840.1.113883.5.4"/> <statusCode code="completed"/> <effectiveTime/> <consumable> <manufacturedProduct classCode="MANU"> <templateId root="1.2.40.0.34.11.13.3.22"/> <manufacturedMaterial classCode="MMAT"> <templateId root="1.2.40.0.34.11.2.3.4"/> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.1"/> <code> <translation/> </code> <lotNumberText>lotNumberText</lotNumberText> <manufacturerOrganization classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr>  </manufacturerOrganization> </manufacturedMaterial> </manufacturedProduct>  </consumable> <author typeCode="AUT" contextControlCode="OP"> <time value="20181011124843"/> <assignedAuthor classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="--code--" codeSystem="1.2.40.0.34.10.6"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <__CHOICE__ min="1" max="1">  <assignedPerson>  <name>name</name> </assignedPerson>   <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE"> <manufacturerModelName>manufacturerModelName</manufacturerModelName> <softwareName>softwareName</softwareName> </assignedAuthoringDevice>  </__CHOICE__> <representedOrganization classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganization> </assignedAuthor>  </author> <informant typeCode="INF" contextControlCode="OP"> <__CHOICE__ min="1" max="1">  <assignedEntity classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="100" codeSystem="1.2.40.0.34.5.2" displayName="Ärztin/Arzt für Allgemeinmedizin"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <assignedPerson>  <name>name</name> </assignedPerson> <representedOrganisation classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganisation> </assignedEntity>   <relatedEntity classCode="PRS"> <code code="FAMMEMB" codeSystem="2.16.840.1.113883.5.111" displayName="Family Member"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <relatedPerson>  <name>name</name> </relatedPerson> </relatedEntity>  </__CHOICE__>  </informant> <reference> <externalDocument classCode="DOC" moodCode="EVN"> <id root="1.2.3.999" extension="--example only--"/> <code/> <text/> </externalDocument>  </reference> </substanceAdministration>  </entry> </section>  </component>   <component> <section> <templateId root="1.2.40.0.34.11.13.2.8"/> <id root="1.2.3.999" extension="--example only--"/> <code code="29762-2" codeSystem="2.16.840.1.113883.6.1"/> <title>Lebensstil</title> <text/> <author typeCode="AUT" contextControlCode="OP"> <time value="20181011124843"/> <assignedAuthor classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="--code--" codeSystem="1.2.40.0.34.10.6"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <__CHOICE__ min="1" max="1">  <assignedPerson>  <name>name</name> </assignedPerson>   <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE"> <manufacturerModelName>manufacturerModelName</manufacturerModelName> <softwareName>softwareName</softwareName> </assignedAuthoringDevice>  </__CHOICE__> <representedOrganization classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganization> </assignedAuthor>  </author> <informant typeCode="INF" contextControlCode="OP"> <__CHOICE__ min="1" max="1">  <assignedEntity classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="100" codeSystem="1.2.40.0.34.5.2" displayName="Ärztin/Arzt für Allgemeinmedizin"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <assignedPerson>  <name>name</name> </assignedPerson> <representedOrganisation classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganisation> </assignedEntity>   <relatedEntity classCode="PRS"> <code code="FAMMEMB" codeSystem="2.16.840.1.113883.5.111" displayName="Family Member"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <relatedPerson>  <name>name</name> </relatedPerson> </relatedEntity>  </__CHOICE__>  </informant> <entry typeCode="DRIV"> <observation classCode="OBS" moodCode="EVN"> <templateId root="1.2.40.0.34.11.13.3.11"/> <id root="1.2.3.999" extension="--example only--"/> <code code="229819007" codeSystem="2.16.840.1.113883.6.96"/> <statusCode code="completed"/> <effectiveTme> <low value="20181011124843"/> </effectiveTme> <value type="CD"/> <author typeCode="AUT" contextControlCode="OP"> <time value="20181011124843"/> <assignedAuthor classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="--code--" codeSystem="1.2.40.0.34.10.6"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <__CHOICE__ min="1" max="1">  <assignedPerson>  <name>name</name> </assignedPerson>   <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE"> <manufacturerModelName>manufacturerModelName</manufacturerModelName> <softwareName>softwareName</softwareName> </assignedAuthoringDevice>  </__CHOICE__> <representedOrganization classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganization> </assignedAuthor>  </author> <informant typeCode="INF" contextControlCode="OP"> <__CHOICE__ min="1" max="1">  <assignedEntity classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="100" codeSystem="1.2.40.0.34.5.2" displayName="Ärztin/Arzt für Allgemeinmedizin"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <assignedPerson>  <name>name</name> </assignedPerson> <representedOrganisation classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganisation> </assignedEntity>   <relatedEntity classCode="PRS"> <code code="FAMMEMB" codeSystem="2.16.840.1.113883.5.111" displayName="Family Member"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <relatedPerson>  <name>name</name> </relatedPerson> </relatedEntity>  </__CHOICE__>  </informant> <reference> <externalDocument classCode="DOC" moodCode="EVN"> <id root="1.2.3.999" extension="--example only--"/> <code/> <text/> </externalDocument>  </reference> </observation>  </entry> <entry typeCode="DRIV"> <observation classCode="OBS" moodCode="EVN"> <templateId root="1.2.40.0.34.11.13.3.25"/> <id root="1.2.3.999" extension="--example only--"/> <code code="160573003" codeSystem="2.16.840.1.113883.6.96" displayName="Alcohol intake"/> <statusCode code="completed"/> <effectiveTime> <low value="20181011124843"/> </effectiveTime> <value type="PQ"/> <author typeCode="AUT" contextControlCode="OP"> <time value="20181011124843"/> <assignedAuthor classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="--code--" codeSystem="1.2.40.0.34.10.6"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <__CHOICE__ min="1" max="1">  <assignedPerson>  <name>name</name> </assignedPerson>   <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE"> <manufacturerModelName>manufacturerModelName</manufacturerModelName> <softwareName>softwareName</softwareName> </assignedAuthoringDevice>  </__CHOICE__> <representedOrganization classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganization> </assignedAuthor>  </author> <informant typeCode="INF" contextControlCode="OP"> <__CHOICE__ min="1" max="1">  <assignedEntity classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="100" codeSystem="1.2.40.0.34.5.2" displayName="Ärztin/Arzt für Allgemeinmedizin"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <assignedPerson>  <name>name</name> </assignedPerson> <representedOrganisation classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganisation> </assignedEntity>   <relatedEntity classCode="PRS"> <code code="FAMMEMB" codeSystem="2.16.840.1.113883.5.111" displayName="Family Member"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <relatedPerson>  <name>name</name> </relatedPerson> </relatedEntity>  </__CHOICE__>  </informant> <reference> <externalDocument classCode="DOC" moodCode="EVN"> <id root="1.2.3.999" extension="--example only--"/> <code/> <text/> </externalDocument>  </reference> </observation>  </entry> </section>  </component>   <component> <section> <templateId root="1.2.40.0.34.11.13.2.11"/> <code code="42348-3" codeSystem="2.16.840.1.113883.6.1"/> <title>Willenserklärungen und andere juridische Dokumente</title> <text/> <author typeCode="AUT" contextControlCode="OP"> <time value="20181011124843"/> <assignedAuthor classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="--code--" codeSystem="1.2.40.0.34.10.6"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <__CHOICE__ min="1" max="1">  <assignedPerson>  <name>name</name> </assignedPerson>   <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE"> <manufacturerModelName>manufacturerModelName</manufacturerModelName> <softwareName>softwareName</softwareName> </assignedAuthoringDevice>  </__CHOICE__> <representedOrganization classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganization> </assignedAuthor>  </author> <informant typeCode="INF" contextControlCode="OP"> <__CHOICE__ min="1" max="1">  <assignedEntity classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="100" codeSystem="1.2.40.0.34.5.2" displayName="Ärztin/Arzt für Allgemeinmedizin"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <assignedPerson>  <name>name</name> </assignedPerson> <representedOrganisation classCode="ORG" determinerCode="INSTANCE"> <id root="1.2.3.999" extension="--example only--"/> <name>name</name> <telecom value="tel:+1-12345678"/> <addr>addr</addr> </representedOrganisation> </assignedEntity>   <relatedEntity classCode="PRS"> <code code="FAMMEMB" codeSystem="2.16.840.1.113883.5.111" displayName="Family Member"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/> <relatedPerson>  <name>name</name> </relatedPerson> </relatedEntity>  </__CHOICE__>  </informant> </section>  </component>  </__CHOICE__></section>

Item DT Kard Konf Beschreibung Label

hl7:section

0 … 1

(Ana...ese)


	elgagab-dataelement-169	Anamnese	Datensatz

hl7:templateId

II

1 … 1

M

(Ana...ese)

@root

uid

1 … 1

F

1.2.40.0.34.11.14.2.6

hl7:code

CE

1 … 1

M

(Ana...ese)

@code

CONF

1 … 1

F

10164-2

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

@codeSystemName

1 … 1

F

LOINC

@displayName

1 … 1

F

History of present illness

hl7:title

ST

1 … 1

M

(Ana...ese)

CONF

Elementinhalt muss "Anamnese" sein

hl7:text

SD.TEXT

1 … 1

M

Freitext für aktuelle Anamnese.

Gutes Beispiel: „Thoraxschmerzen bei leichter Belastung seit zwei Wochen. Vorherige Herzprobleme bekannt.“
Schlechtes Beispiel: Kopie sämtlicher Vordiagnosen

(Ana...ese)

Auswahl

0 …

Mögliche Untersektionen:

Schwangerschaften
Medizinische Geräte und Implantate
Beeinträchtigungen
Impfungen
Lebensstil
Willenserklärungen
Fachspezifische Anamnese

Elemente in der Auswahl:

hl7:component welches enthält Template 1.2.40.0.34.11.13.2.9 Schwangerschaften (2017‑03‑11 18:04:25)
hl7:component welches enthält Template 1.2.40.0.34.11.13.2.4 Medizinische Geräte und Implantate (2017‑02‑26 11:36:47)
hl7:component welches enthält Template 1.2.40.0.34.11.13.2.12 Beeinträchtigungen (2017‑08‑04 12:10:57)
hl7:component welches enthält Template 1.2.40.0.34.11.13.2.7 Impfungen (2017‑03‑11 18:38:41)
hl7:component[hl7:section/hl7:templateId/@root='1.2.40.0.34.11.1.2.6'] welches enthält Template 1.2.40.0.34.11.13.2.8 Lebensstil (2017‑03‑12 11:13:38)
hl7:component[hl7:section/hl7:templateId/@root='1.2.40.0.34.11.1.2.7'] welches enthält Template 1.2.40.0.34.11.13.2.11 Willenserklärungen (2017‑08‑04 11:56:28)

hl7:component

0 … 1

Beinhaltet 1.2.40.0.34.11.13.2.9 Schwangerschaften (2017‑03‑11 18:04:25)

(Ana...ese)

wo [hl7:section [hl7:code [(@code = '10162-6' and @codeSystem = '2.16.840.1.113883.6.1')]]]

@typeCode

cs

0 … 1

F

COMP

@contextConductionInd

bl

0 … 1

F

true

hl7:component

0 … 1

Beinhaltet 1.2.40.0.34.11.13.2.4 Medizinische Geräte und Implantate (2017‑02‑26 11:36:47)

(Ana...ese)

wo [hl7:section [hl7:code [(@code = '46264-8' and @codeSystem = '2.16.840.1.113883.6.1')]]]

@typeCode

cs

0 … 1

F

COMP

@contextConductionInd

bl

0 … 1

F

true

hl7:component

0 … 1

Beinhaltet 1.2.40.0.34.11.13.2.12 Beeinträchtigungen (2017‑08‑04 12:10:57)

(Ana...ese)

wo [hl7:section [hl7:code [(@code = '47420-5' and @codeSystem = '2.16.840.1.113883.6.1')]]]

@typeCode

cs

0 … 1

F

COMP

@contextConductionInd

bl

0 … 1

F

true

hl7:component

0 … 1

Beinhaltet 1.2.40.0.34.11.13.2.7 Impfungen (2017‑03‑11 18:38:41)

(Ana...ese)

wo [hl7:section [hl7:code [(@code = '11369-6 ' and @codeSystem = '2.16.840.1.113883.6.1')]]]

@typeCode

cs

0 … 1

F

COMP

@contextConductionInd

bl

0 … 1

F

true

hl7:component

0 … 1

Beinhaltet 1.2.40.0.34.11.13.2.8 Lebensstil (2017‑03‑12 11:13:38)

(Ana...ese)

wo [hl7:section/hl7:templateId/@root='1.2.40.0.34.11.1.2.6']

@typeCode

cs

0 … 1

F

COMP

@contextConductionInd

bl

0 … 1

F

true

hl7:component

0 … 1

Beinhaltet 1.2.40.0.34.11.13.2.11 Willenserklärungen (2017‑08‑04 11:56:28)

(Ana...ese)

wo [hl7:section/hl7:templateId/@root='1.2.40.0.34.11.1.2.7']

@typeCode

cs

0 … 1

F

COMP

@contextConductionInd

bl

0 … 1

F

true

1.2.40.0.34.11.14.2.6/static-2018-10-09T133507

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