1.2.40.0.34.11.14.2.11/static-2018-10-18T115006

Id	1.2.40.0.34.11.14.2.11	Gültigkeit	2018‑10‑18 11:50:06
Status	Entwurf	Versions-Label
Name	Vorbefunde1	Anzeigename	Vorbefunde
Beschreibung	Relevante Befunde, die im Rahmen von vorangegangenen Patientenkontakten von anderen GDA oder selbst erhoben wurden und als freitextliches Zitat (oder Beilage) angegeben werden.
Kontext	Elternknoten des Template-Element mit Id 1.2.40.0.34.11.14.2.11
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-170  Vorbefunde  Datensatz
Benutzt	Benutzt 4 Templates Benutzt als Name Version 1.2.40.0.34.11.13.3.16 Containment Author (Body) PS DYNAMIC 1.2.40.0.34.11.13.3.20 Containment Informant (Body) PS (0.1) DYNAMIC 1.2.40.0.34.11.13.3.26 Containment ELGA Results Organizer (0.1) DYNAMIC 1.2.40.0.34.11.1.2.3 Containment Beilagen 2015‑04‑23
Beispiel	Minimalbeispiel <section>   <!-- ELGA EIS „Enhanced“ und “Full support” -->   <templateId root="1.2.40.0.34.11.14.2.5"/>  <code code="30954-2" codeSystem="2.16.840.1.113883.6.1" displayName="Relevant diagnostic tests/laboratory data Narrative" codeSystemName="LOINC"/>  <!-- Titel der Sektion -->   <title>Vorbefunde</title>  <!-- Textbereich der Sektion -->   <text> ... Lesbarer Textbereich ... </text>  <author>     <!-- template 1.2.40.0.34.11.13.3.16 'Author (Body) PS' (2017-08-05T19:04:45) -->   </author>  <informant>     <!-- template 1.2.40.0.34.11.13.3.20 'Informant (Body) PS' (2017-08-10T20:49:25) -->   </informant>  <entry>     <!-- template 1.2.40.0.34.11.13.3.26 'ELGA Results Organizer' (2017-09-09T17:12:50) -->   </entry>  <entry>     <!-- template 1.2.40.0.34.11.1.2.3 'Beilagen' (2015-04-23T00:00:00) -->   </entry></section>
Beispiel	Vollständiges Beispiel <section>   <!-- ELGA EIS „Enhanced“ und “Full support” -->   <templateId root="1.2.40.0.34.11.14.2.5"/>  <code code="30954-2" codeSystem="2.16.840.1.113883.6.1" displayName="Relevant diagnostic tests/laboratory data Narrative" codeSystemName="LOINC"/>  <!-- Titel der Sektion -->   <title>Vorbefunde</title>  <!-- Textbereich der Sektion -->   <text> ... Lesbarer Textbereich ... </text>  <author typeCode="AUT" contextControlCode="OP">     <time value="20181018130344"/>    <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>  <entry>     <organizer classCode="BATTERY" moodCode="EVN">       <templateId root="1.2.40.0.34.11.13.3.26"/>      <id root="1.2.3.999" extension="--example only--"/>      <code code="1" codeSystem="1.2.40.0.34.5.11" displayName="Allgemeiner Laborbefund"/>      <statusCode/>      <effectiveTime>         <low value="20181018130344"/>      </effectiveTime>      <author typeCode="AUT" contextControlCode="OP">         <time value="20181018130344"/>        <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>      <component>         <observation classCode="OBS" moodCode="EVN">           <templateId root="1.3.6.1.4.1.19376.1.3.1.6"/>          <id root="1.2.3.999" extension="--example only--"/>          <code code="100" codeSystem="1.2.40.0.34.5.11" displayName="Blutgruppenserologie"/>          <text/>          <statusCode code="completed"/>          <effectiveTime>             <low value="20181018130344"/>          </effectiveTime>          <__CHOICE__ min="0" max="1">             <!--start choice particle-->             <value value="1">               <translation/>            </value>            <!--end choice particle-->             <!--start choice particle-->             <value>               <low value="1"/>            </value>            <!--end choice particle-->             <!--start choice particle-->             <value value="1"/>            <!--end choice particle-->             <!--start choice particle-->             <value/>            <!--end choice particle-->             <!--start choice particle-->             <value value="false"/>            <!--end choice particle-->             <!--start choice particle-->             <value>value</value>            <!--end choice particle-->             <!--start choice particle-->             <value/>            <!--end choice particle-->             <!--start choice particle-->             <value value="20181018130344"/>            <!--end choice particle-->             <!--start choice particle-->             <value/>            <!--end choice particle-->             <!--start choice particle-->             <value/>            <!--end choice particle-->             <!--start choice particle-->             <value/>            <!--end choice particle-->             <!--start choice particle-->             <value/>            <!--end choice particle-->           </__CHOICE__>          <interpretationCode code="I" codeSystem="2.16.840.1.113883.5.83" displayName="intermediate"/>          <entryRelationship typeCode="COMP">             <act classCode="ACT" moodCode="EVN">               <templateId root="1.2.40.0.34.11.4.3.2"/>              <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"/>              <text>                 <reference value="--TODO--"/>              </text>              <statusCode code="completed"/>            </act>            <!-- template 1.2.40.0.34.11.4.3.2 'Befundtext (Anmerkungen und Kommentare)' (2015-01-30T00:00:00) -->           </entryRelationship>          <participant typeCode="AUTHEN">             <templateId root="1.3.6.1.4.1.19376.1.3.3.1.5"/>            <time>               <low value="20181018130344"/>            </time>            <participantRole>               <id root="1.2.3.999" extension="--example only--"/>              <addr>addr</addr>              <telecom value="tel:+1-12345678"/>              <playingEntity>                 <name>name</name>              </playingEntity>            </participantRole>          </participant>          <referenceRange typeCode="REFV">             <observationRange classCode="OBS" moodCode="EVN.CRT">               <text>                 <reference value="tel:+1-12345678"/>              </text>              <value>                 <low value="1"/>                <high value="1"/>              </value>              <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>            </observationRange>          </referenceRange>          <performer>             <templateId root="1.2.40.0.34.11.4.3.3"/>            <time>               <low value="20181018130344"/>            </time>            <assignedEntity>               <id root="1.2.3.999" extension="--example only--"/>              <code code="E" codeSystem="2.16.840.1.113883.2.16.1.4.9" displayName="EXTERN"/>              <addr>addr</addr>              <telecom value="tel:+1-12345678"/>              <__CHOICE__ min="1">                 <!--start choice particle-->                 <assignedPerson>                   <!-- include template 1.2.40.0.34.11.90001 'PersonElements' (2011-12-19T00:00:00) -->                   <name>name</name>                </assignedPerson>                <!--end choice particle-->                 <!--start choice particle-->                 <representedOrganization>                   <!-- include template 1.2.40.0.34.11.90002 'OrganizationElements' (2011-12-19T00:00:00) -->                   <id root="1.2.3.999" extension="--example only--"/>                  <name>name</name>                  <telecom value="tel:+1-12345678"/>                  <addr>addr</addr>                </representedOrganization>                <!--end choice particle-->               </__CHOICE__>            </assignedEntity>            <!-- template 1.2.40.0.34.11.4.3.3 'Laboratory Performer 2' (2014-12-06T00:00:00) -->           </performer>        </observation>        <!-- template 1.3.6.1.4.1.19376.1.3.1.6 'Laborergebnisse (Laboratory Observation)' (2015-03-26T00:00:00) -->       </component>      <component>         <observation classCode="OBS" moodCode="EVN">           <templateId root="1.2.40.0.34.11.13.3.12"/>          <id root="1.2.3.999" extension="--example only--"/>          <code code="--code--" codeSystem="2.16.840.1.113883.6.1"/>          <statusCode code="completed"/>          <effectiveTime>             <low value="20181018130344"/>          </effectiveTime>          <__CHOICE__ min="1" max="1">             <!--start choice particle-->             <value type="CD"/>            <!--end choice particle-->             <!--start choice particle-->             <value type="PQ" value="1" unit="cs"/>            <!--end choice particle-->             <!--start choice particle-->             <value/>            <!--end choice particle-->           </__CHOICE__>          <interpretationCode code="I" codeSystem="2.16.840.1.113883.5.83" displayName="intermediate"/>          <methodCode/>          <targetSiteCode/>          <referenceRange>             <observationRange>               <value/>              <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" displayName="HL7:ObservationInterpretation"/>            </observationRange>          </referenceRange>        </observation>        <!-- template 1.2.40.0.34.11.13.3.12 'ELGA Result Observation' (2017-09-17T16:45:42) -->       </component>      <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>    </organizer>    <!-- template 1.2.40.0.34.11.13.3.26 'ELGA Results Organizer' (2017-09-09T17:12:50) -->   </entry>  <entry>     <section>       <templateId root="1.2.40.0.34.11.1.2.3"/>      <code code="BEIL" codeSystem="1.2.40.0.34.5.40"/>      <title>Beilagen</title>      <text/>      <entry>         <observationMedia classCode="OBS" moodCode="EVN" ID="--TODO--">           <templateId root="1.2.40.0.34.11.1.3.1"/>          <value mediaType="application/dicom" representation="B64"/>        </observationMedia>        <!-- template 1.2.40.0.34.11.1.3.1 'Eingebettetes Objekt Entry' (2017-05-05T00:00:00) -->       </entry>    </section>    <!-- template 1.2.40.0.34.11.1.2.3 'Beilagen' (2015-04-23T00:00:00) -->   </entry></section>
Item DT Kard Konf Beschreibung Label hl7:section R (Vor...de1)   elgagab-data​element-170  Vorbefunde  Datensatz hl7:templateId II 1 … 1 M (Vor...de1) @root oid 1 … 1 F 1.2.40.0.34.11.14.2.11 hl7:code CE (extensible) 1 … 1 M (Vor...de1) @code CONF 1 … 1 F 30954-2 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (LOINC) @codeSystemName 1 … 1 F LOINC @displayName 1 … 1 F Relevant diagnostic tests/laboratory data Narrative hl7:title ST 1 … 1 M (Vor...de1)   CONF Elementinhalt muss "Vorbefunde" sein hl7:text SD.TEXT 1 … 1 M (Vor...de1) hl7:author 0 … * Author der enthaltenen Information (GDA) Beinhaltet 1.2.40.0.34.11.13.3.16 Author (Body) PS (DYNAMIC) (Vor...de1) wo [hl7:assignedAuthor] hl7:informant 0 … * Quelle für die enthaltene Information Name der Person und ihre Beziehung zum Patienten (Patient oder Angehöriger, Auskunftsperson - nicht-GDA) Beinhaltet 1.2.40.0.34.11.13.3.20 Informant (Body) PS (DYNAMIC) (Vor...de1) hl7:entry 0 … * R Beinhaltet 1.2.40.0.34.11.13.3.26 ELGA Results Organizer (DYNAMIC) (Vor...de1) wo [hl7:organizer] @typeCode cs 0 … 1 F DRIV hl7:entry 0 … * Beinhaltet 1.2.40.0.34.11.1.2.3 Beilagen (2015‑04‑23) (Vor...de1) wo [hl7:section [hl7:code [(@code = 'BEIL' and @codeSystem = '1.2.40.0.34.5.40')]]]