1.2.40.0.34.11.14.2.3/static-2018-10-17T133939

Id	1.2.40.0.34.11.14.2.3	Gültigkeit	2018‑10‑17 13:39:39
Status	Entwurf	Versions-Label
Name	KonsultUeberweisungsgrund	Anzeigename	Konsultations- oder Überweisungsgrund
Beschreibung Der Grund für eine Gesundheitsdienstleistung (z.B. Behandlung). Enthält eine kurze narrative Beschreibung des Hauptsymptoms des Patienten (eigene Beschreibung des Patienten) und/oder den Grund für den Patientenbesuch (Beschreibung aus der Sicht des Gesundheitsdiensteanbieters). Beispiele: „Thoraxschmerz“, „Atemnot“, „Kopfweh“ Gutes Beispiel: „Allergietest und Therapieeinleitung erbeten“ Schlechtes Beispiel: „Fachärztliche Abklärung erbeten"
Kontext	Elternknoten des Template-Element mit Id 1.2.40.0.34.11.14.2.3
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-data​element-4  Konsultations- oder Überweisungsgrund  Datensatz
Benutzt	Benutzt 1 Template Benutzt als Name Version 1.2.40.0.34.11.13.3.6 Containment Gesundheitsproblem Bedenken Entry (0.2) 2017‑01‑26 14:29:54
Beispiel	Strukturbeispiel <section>   <templateId/>  <code code="46239-0" codeSystem="2.16.840.1.113883.6.1" displayName="Chief complaint+Reason for visit"/>  <title>Konsultations- oder Überweisungsgrund</title>  <text/>  <entry>     <act classCode="ACT" moodCode="EVN">       <templateId root="1.2.40.0.34.11.13.3.6"/>      <id/>      <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>      <statusCode code="active"/>      <effectiveTime>         <low/>        <high/>      </effectiveTime>      <author typeCode="AUT" contextControlCode="OP">         <time value="20181017135215"/>        <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">             <!--start choice particle-->             <assignedPerson>               <!-- include template 1.2.40.0.34.11.90001 'PersonElements' (2011-12-19T00:00:00) 1..1 M -->               <name>name</name>            </assignedPerson>            <!--end choice particle-->             <!--start choice particle-->             <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">               <manufacturerModelName>manufacturerModelName</manufacturerModelName>              <softwareName>softwareName</softwareName>            </assignedAuthoringDevice>            <!--end choice particle-->           </__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>        <!-- template 1.2.40.0.34.11.13.3.16 'Author (Body) PS' (2017-08-05T19:04:45) -->       </author>      <informant typeCode="INF" contextControlCode="OP">         <__CHOICE__ min="1" max="1">           <!--start choice particle-->           <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>               <!-- include template 1.2.40.0.34.11.90001 'PersonElements' (2011-12-19T00:00:00) -->               <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>          <!--end choice particle-->           <!--start choice particle-->           <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>               <!-- include template 1.2.40.0.34.11.90001 'PersonElements' (2011-12-19T00:00:00) -->               <name>name</name>            </relatedPerson>          </relatedEntity>          <!--end choice particle-->         </__CHOICE__>        <!-- template 1.2.40.0.34.11.13.3.20 'Informant (Body) PS' (2017-08-10T20:49:25) -->       </informant>      <entryRelationship typeCode="SUBJ" inversionInd="false">         <observation classCode="OBS" moodCode="EVN">           <templateId root="1.2.40.0.34.11.13.3.7"/>          <id/>          <code/>          <text>             <reference value="value"/>          </text>          <statusCode code="completed"/>          <effectiveTime>             <low/>            <high/>          </effectiveTime>          <value type="CD">             <originalText>               <reference value="tel:+1-12345678"/>            </originalText>            <translation/>          </value>          <entryRelationship typeCode="SUBJ" inversionInd="true">             <observation classCode="OBS" moodCode="EVN">               <templateId root="1.2.40.0.34.11.13.3.21"/>              <id root="1.2.3.999" extension="--example only--"/>              <code code="SEV"/>              <text>                 <reference value="--TODO--"/>              </text>              <statusCode code="completed"/>              <value type="CD"/>            </observation>            <!-- template 1.2.40.0.34.11.13.3.21 'Severity Observation' (2017-08-20T12:08:35) -->           </entryRelationship>          <entryRelationship typeCode="SUBJ" inversionInd="true">             <observation classCode="OBS" moodCode="EVN">               <templateId root="1.2.40.0.34.11.13.3.19"/>              <code code="--code--" codeSystem="2.16.840.1.113883.6.1"/>              <text>                 <reference value="--TODO--"/>              </text>              <statusCode code="completed"/>              <value type="CD"/>            </observation>            <!-- template 1.2.40.0.34.11.13.3.19 'Certainty Observation' (2017-08-10T20:25:54) -->           </entryRelationship>          <entryRelationship typeCode="REFR" inversionInd="false">             <observation classCode="OBS" moodCode="EVN">               <templateId root="1.2.40.0.34.11.13.3.13"/>              <code code="33999-4" codeSystem="2.16.840.1.113883.6.1"/>              <text>                 <reference value="--TODO--"/>              </text>              <statusCode code="completed"/>              <value type="CD"/>            </observation>            <!-- template 1.2.40.0.34.11.13.3.13 'Problem Status Observation' (2017-07-13T21:04:49) -->           </entryRelationship>        </observation>        <!-- template 1.2.40.0.34.11.13.3.7 'Problem Entry Gesundheitsproblem' (2017-08-13T15:08:52) -->       </entryRelationship>      <reference>         <externalDocument classCode="DOC" moodCode="EVN">           <id root="1.2.3.999" extension="--example only--"/>          <code/>          <text/>        </externalDocument>        <!-- template 1.2.40.0.34.11.13.3.17 'ELGA ExternalDocument' (2017-08-09T10:55:40) -->       </reference>    </act>    <!-- template 1.2.40.0.34.11.13.3.6 'Gesundheitsproblem Bedenken Entry' (2017-01-26T14:29:54) -->   </entry></section>
Item DT Kard Konf Beschreibung Label hl7:section (Kon...und)   elgagab-data​element-4  Konsultations- oder Überweisungsgrund  Datensatz hl7:templateId II 1 … 1 M (Kon...und) @root oid 1 … 1 F 1.2.40.0.34.11.14.2.3 hl7:code CE 1 … 1 M (Kon...und) @code CONF 1 … 1 F 46239-0 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (LOINC) @codeSystemName 1 … 1 F LOINC @displayName 1 … 1 F Chief complaint+Reason for visit hl7:title ST 1 … 1 M (Kon...und)   CONF Elementinhalt muss "Konsultations- oder Überweisungsgrund" sein hl7:text SD.TEXT 1 … 1 M Information für den menschlichen Leser. (Kon...und) hl7:entry 0 … * Beinhaltet 1.2.40.0.34.11.13.3.6 Gesundheitsproblem Bedenken Entry (2017‑01‑26 14:29:54) (Kon...und) wo [hl7:act [hl7:code [(@code = 'CONC' and @codeSystem = '2.16.840.1.113883.5.6') or @nullFlavor]]]