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1.2.40.0.34.6.0.11.0.5/static-2019-05-10T090427

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<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;">1.2.40.0.34.6.0.11.0.5</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2019‑05‑10 09:04:27<div>Andere Versionen mit dieser Id:<ul><li>[[File:Kblank.png|14px]] elgaambbef_document_ambulanzbefund vom 2022‑06‑07 10:53:37</li><li>[[File:Kblank.png|14px]] elgaambbef_document_ambulanzbefund vom 2022‑06‑03 10:49:13</li><li>[[File:Kblank.png|14px]] elgaambbef_document_ambulanzbefund vom 2021‑10‑27 13:18:25</li><li>[[File:Kblank.png|14px]] elgaambbef_document_ambulanzbefund vom 2021‑02‑08 13:01:55</li><li>[[File:Kblank.png|14px]] elgaambbef_document_ambulanzbefund vom 2020‑10‑09 11:29:46</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:Kgreen.png|14px]] Aktiv</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;">2020</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">elgaambbef_document_ambulanzbefund</td><th style="width: 20em; text-align: left;">Bezeichnung</th><td style="text-align: left;">Ambulanzbefund</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>Der Ambulanzbefund stellt das Berichtwesen an weitere versorgende GDAs und den Patienten/die Patientin einer ambulanten Versorgung dar. Diese Spezifikation stellt im Allgemeinen die gemeinsamen Richtlinien und Anforderungen an Ambulanzbefunde, unabhängig von der medizinischen Fachrichtung, dar. Fachrichtungsspezifische Inhalte sind möglich, jedoch könnte es noch

einer genaueren und innerhalb der Fachrichtung harmonisierten Darstellung benötigen.</div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Kontext</th><td style="text-align: left;" colspan="3">Pfadname /</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Document Level Template</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Offen/Geschlossen</th><td style="text-align: left;" colspan="3">Geschlossen (nur definierte Elemente sind erlaubt)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Benutzt</th><td style="text-align: left;" colspan="3"><table width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Benutzt 53 Templates</td></tr><tr><td><div><table width="100%" border="0" cellspacing="1" cellpadding="3" class="artdecor " style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Benutzt</th><th style="width: 1%; text-align: left;"> als </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.10</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Document Realm (1.0.1)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.30</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Document TypeId (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.1</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Document Id (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.45</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Document StatusCode (1.0.1+20210624)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.46</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Document TerminologyDate (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.44</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Document PracticeSettingCode (1.1.0+20210303)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.11</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:~~Kgreen~~Kyellow.png|14px]] Document Effective Time (1.0.~~0+20210219~~1)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.12</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Document Confidentiality Code (1.0.2)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.13</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Document Language (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.15</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Document Set Id and Version Number (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.3</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Record Target (1.2.0+20210303)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.2</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Author (1.0.3)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.22</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Data Enterer (1.0.1)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.4</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Custodian (1.0.1+20211213)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.24</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Information Recipient (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.5</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Legal Authenticator (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.6</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Authenticator (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.20</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Participant Fachlicher Ansprechpartner (1.0.2+20210803)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.23</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Participant Hausarzt (1.0.1+20210803)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.27</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Participant Auskunftsberechtigte Person (Notfallkontakt) (1.0.2+20210803)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.25</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Participant Angehoerige (1.0.1+20210803)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.26</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Participant Versicherung (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.29</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Participant Betreuungsorganisation (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.28</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Participant Weitere Behandler (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.21</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Participant Ein-, Ueber-, Zuweisender Arzt (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.9</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] In Fulfillment Of (1.0.1+20210628)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.33</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Documentation Of Service Event - Outpatient Report (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.14</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Document Replacement - Related Document (1.0.1+20210628)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.7</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Component Of - Encompassing Encounter (1.0.1)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.69</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Brieftext (1.0.1+20210628)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.17</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Konsultations- oder Überweisungsgrund - unkodiert (1.0.0+20201119)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.47</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Konsultations- oder Überweisungsgrund - kodiert (1.1.0+20201123 )</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.9</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Aktuelle Medikation - unkodiert (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.63</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Medikationsliste PS - kodiert (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.41</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Allergien und Intoleranzen - unkodiert (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.59</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Allergien und Intoleranzen - kodiert (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.10</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Anamnese (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.11</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Status, Diagnostik und Befunde - unkodiert (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.57</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Status, Diagnostik und Befunde - kodiert (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.83</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Diagnose - unkodiert (1.0.1+20210304)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.96</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Diagnose - kodiert (1.1.1+20210304)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.12</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Verlauf (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.25</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Zusammenfassende Beurteilung (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.22</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Durchgeführte Maßnahmen - unkodiert (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.13</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Durchgeführte Maßnahmen - kodiert (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.56</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Empfohlene Medikation - unkodiert (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.21</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Empfohlene Medikation - kodiert (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.23</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Weitere empfohlene Maßnahmen - unkodiert (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.58</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Weitere empfohlene Maßnahmen - kodiert (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.26</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Weitere Informationen (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.61</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Willenserklärungen und andere juridische Dokumente (1.1.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.70</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Abschließende Bemerkung (1.0.1+20210628)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.71</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Beilagen (1.0.2)</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr><th style="width: 30%; text-align: left;">Item</th><th style="width: 2em; text-align: left;">DT</th><th style="width: 2em; text-align: left;">Kard</th><th style="width: 2em; text-align: left;">Konf</th><th style="text-align: left;">Beschreibung</th><th style="width: 2em; text-align: left;">Label</th></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td>hl7:ClinicalDocument </td></tr></table></td><td></td><td>1 … 1</td><td>M</td><td></td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@classCode </td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">DOCCLIN</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@moodCode </td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td>1 … 1</td><td>M</td><td colspan="2"> von 1.2.40.0.34.6.0.11.1.10 Document Realm (DYNAMIC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:realmCode </td></tr></table></td><td>CS</td><td>1 … 1</td><td>M</td><td><div>Hoheitsbereich des Dokuments. </div><div>Fester Wert: @code = AT</div><div>(aus Value Set „ELGA_RealmCode“)</div></td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@code </td></tr></table></td><td></td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">AT</td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td>1 … 1</td><td>M</td><td colspan="2"> von 1.2.40.0.34.6.0.11.1.30 Document TypeId (DYNAMIC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:typeId </td></tr></table></td><td>II</td><td>1 … 1</td><td>M</td><td>Dokumentformat CDA R2 </td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@root </td></tr></table></td><td>uid</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">2.16.840.1.113883.1.3</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@extension </td></tr></table></td><td>st</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">POCD_HD000040</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:templateId </td></tr></table></td><td>II</td><td>1 … 1</td><td>M</td><td>eHealth Austria Dokumente ("Allgemeiner Leitfaden") </td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@root </td></tr></table></td><td>uid</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.40.0.34.6.0.11.0.1</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:templateId </td></tr></table></td><td>II</td><td>1 … 1</td><td>M</td><td>OID des Leitfadens Ambulanzbefund</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@root </td></tr></table></td><td>uid</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.40.0.34.7.22</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:templateId </td></tr></table></td><td>II</td><td>1 … 1</td><td>M</td><td>templateId des Ambulanzbefundes</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@root </td></tr></table></td><td>uid</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.40.0.34.6.0.11.0.5</td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td>1 … 1</td><td></td><td colspan="2"><div>templateId zur Codierung der ELGA Interoperabilitätsstufe (EIS) </div>Elemente in der Auswahl:<ul><li>hl7:templateId</li><li>hl7:templateId</li></ul></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:templateId </td></tr></table></td><td>II</td><td>0 … 1</td><td>R</td><td>EIS enhanced default für alle allgemeine Ambulanzbefunde</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@root </td></tr></table></td><td>uid</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.40.0.34.6.0.11.0.5.0.2</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:templateId </td></tr></table></td><td>II</td><td>0 … 1</td><td>R</td><td>EIS full support für Dokumente welche die Sektionen "Allergien und Intoleranzen", "Diagnose" und "Durchgeführte Maßnahmen" in der codierten Form führen (wenn diese vorhanden sind)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@root </td></tr></table></td><td>uid</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.40.0.34.6.0.11.0.5.0.3</td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td>1 … 1</td><td>M</td><td colspan="2"> von 1.2.40.0.34.6.0.11.1.1 Document Id (DYNAMIC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:id </td></tr></table></td><td>II</td><td>1 … 1</td><td>M</td><td>Dokumenten-Id des CDA-Dokuments. Es MUSS eine gültige und innerhalb des ID-Pools eindeutige Dokumenten-ID angegeben werden. Grundsätzlich sind die Vorgaben gemäß „Identifikations-Elemente“ zu befolgen. </td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@root </td></tr></table></td><td>uid</td><td>1 … 1</td><td>R</td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:code </td></tr></table></td><td>CE</td><td>1 … 1</td><td>M</td><td>Der clinicalDocument/code wird in die XDS-Metadaten als classCode übernommen. Die verpflichtenden "translation" wird in die XDS-Metadaten als typeCode übernommen.</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@code </td></tr></table></td><td rowspan="4" class="conf">CONF</td><td>1 … 1</td><td>F</td><td colspan="2">75476-2</td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@codeSystem </td></tr></table></td><td>1 … 1</td><td>F</td><td colspan="2">2.16.840.1.113883.6.1 (LOINC)</td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@codeSystemName </td></tr></table></td><td>1 … 1</td><td>F</td><td colspan="2">LOINC</td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@displayName </td></tr></table></td><td>1 … 1</td><td>F</td><td colspan="2">Physician Note</td></tr><tr class="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Beispiel</td><td colspan="4" class="explabelblue"><code code="75476-2" codeSystem="2.16.840.1.113883.6.1" displayName="Physician Note" codeSystemName="LOINC"> <translation code="34764-1" codeSystem="2.16.840.1.113883.6.1" displayName="General medicine Consult note" codeSystemName="LOINC"/></code></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:translation </td></tr></table></td><td>CD</td><td>1 … 1</td><td>M</td><td>Bei dem ValueSet ELGA_Dokumentenklasse_Ambulanzbefund handelt es sich um ein Sub-Set des Wertevorrats "HL7-at_XDS-Dokumentenklassen", welcher alle HL7 Dokumentenklassen für den Gebrauch in eHealth Austria definiert.</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 1.2.40.0.34.6.0.10.20 ELGA_Dokumentenklasse_Ambulant (DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:title </td></tr></table></td><td>ST</td><td>1 … 1</td><td>M</td><td>Der Title des CDA Dokuments MUSS die Art des Dokuments wiederspiegeln. Vorgeschlagene Titel wären zum Beispiel "Ambulanzbefund" ,"Ambulanzbrief" oder "ambulanter Entlassungsbrief".</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td>0 … 1</td><td>C</td><td colspan="2"> von 1.2.40.0.34.6.0.11.1.45 Document StatusCode (DYNAMIC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>sdtc:statusCode </td></tr></table></td><td>CS</td><td>0 … 1</td><td>C</td><td>

<div>

<div>Status eines Dokuments. e-Befunde sind grundsätzlich abgeschlossene bzw. "fertige" ("completed") Dokumente, daher entfällt die Angabe eines Status. In folgenden Ausnahmen SOLL der Status eines Dokuments wie folgt angegeben werden: </div>

<div>Zulässige Werte für sdtc:statusCode/@code sind "active" und "nullified" </div>

</td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>@code muss "nullified" sein</td></tr><tr style="vertical-align: top;"><td>oder</td></tr><tr style="vertical-align: top;"><td>@code muss "active" sein</td></tr></table></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td>1 … 1</td><td>M</td><td colspan="2"> von 1.2.40.0.34.6.0.11.1.46 Document TerminologyDate (DYNAMIC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7at:terminologyDate </td></tr></table></td><td>TS.DATE.FULL</td><td>1 … 1</td><td>M</td><td>Das Terminologie-Datum des Dokumentes Das Datum, an dem die lokal zur Implementierung verwendeten Value Sets mit dem österreichischen Terminologieserver abgeglichen wurden, wird hier angegeben. </td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4">Das Datum der letzten Terminologie-Aktualisierung MUSS entsprechend klassischer HL7 V3 Notation im Format "YYYYMMDD" angegeben werden. Beispiel: 20200527 </td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7at:formatCode </td></tr></table></td><td>CS</td><td>1 … 1</td><td>M</td><td>Kennzeichnung, ob in der CDA-Instanz über den zugrunde liegenden speziellen Implementierungsleitfaden hinaus weitere, selbst-definierte maschinenlesbare Elemente strukturiert werden. Wenn ja, wird dies durch ein zusätzliches "+"-Zeichen am Ende des codes signalisiert. Wenn nicht, entfällt das "+"-Zeichen <div>↔ Hinweis zum XDS-Mapping: @code wird in das XDS-Attribut XDSDocumentEntry.formatCode übernommen.</div></td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>@code muss "urn:hl7-at:arztb:2020:EIS_Enhanced" sein</td></tr><tr style="vertical-align: top;"><td>oder</td></tr><tr style="vertical-align: top;"><td>@code muss "urn:hl7-at:arztb:2020:EIS_Enhanced+" sein</td></tr><tr style="vertical-align: top;"><td>oder</td></tr><tr style="vertical-align: top;"><td>@code muss "urn:hl7-at:arztb:2020:EIS_FullSupport" sein</td></tr><tr style="vertical-align: top;"><td>oder</td></tr><tr style="vertical-align: top;"><td>@code muss "urn:hl7-at:arztb:2020:EIS_FullSupport+" sein</td></tr></table></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td>1 … 1</td><td>M</td><td colspan="2"> von 1.2.40.0.34.6.0.11.1.44 Document PracticeSettingCode (DYNAMIC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7at:practiceSettingCode </td></tr></table></td><td>CD</td><td>1 … 1</td><td>M</td><td>Die fachliche Zuordnung des Dokumentes</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@displayName </td></tr></table></td><td></td><td>1 … 1</td><td>R</td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 1.2.40.0.34.10.75 atcdabbr_PracticeSetting_VS (DYNAMIC)</td></tr></table></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td>1 … 1</td><td>M</td><td colspan="2"> von 1.2.40.0.34.6.0.11.1.11 Document Effective Time (DYNAMIC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:effectiveTime </td></tr></table></td><td>TS.AT.TZ</td><td>1 … 1</td><td>M</td><td>

<div>Relevantes Datum des Dokuments. Grundsätzlich sind die Vorgaben für „Zeit-Elemente“ zu befolgen. </div>

</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="2">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">at-cda-bbr-dataelement-11</td><td style="vertical-align: top;" title="Headerelemente / ">[[File:Kyellow.png|14px]] Erstellungsdatum </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] Dataset A Allgemeiner Leitfaden </td></tr></table></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td>1 … 1</td><td>M</td><td colspan="2"> von 1.2.40.0.34.6.0.11.1.12 Document Confidentiality Code (DYNAMIC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:confidentialityCode </td></tr></table></td><td>CE</td><td>1 … 1</td><td>M</td><td><div>Vertraulichkeitscode des Dokuments aus Value Set „ELGA_Confidentiality“. </div></td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="2">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">at-cda-bbr-dataelement-13</td><td style="vertical-align: top;" title="Headerelemente / ">[[File:Kyellow.png|14px]] Vertraulichkeitscode </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] Dataset A Allgemeiner Leitfaden </td></tr></table></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@codeSystemName </td></tr></table></td><td>st</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">HL7:Confidentiality</td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4">Für ELGA-Dokumente ist ausschließlich "N" erlaubt! </td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td>1 … 1</td><td>M</td><td colspan="2"> von 1.2.40.0.34.6.0.11.1.13 Document Language (DYNAMIC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:languageCode </td></tr></table></td><td>CS.LANG</td><td>1 … 1</td><td>M</td><td>Sprachcode des Dokuments. </td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="2">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">at-cda-bbr-dataelement-14</td><td style="vertical-align: top;" title="Headerelemente / ">[[File:Kyellow.png|14px]] Sprachcode </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] Dataset A Allgemeiner Leitfaden </td></tr></table></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@code </td></tr></table></td><td>cs</td><td>1 … 1</td><td>R</td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 1.2.40.0.34.10.10 ELGA_LanguageCode (DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4">Für ELGA ist in @code für CDA und Ableitungen in die XDSDocumentEntry-Metadaten derzeit ausschließlich der Wert "de-AT" zulässig. Für eHealth und zukünftige Versionen der ELGA Leitfäden können weitere Sprachcodes erlaubt werden.</td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td>1 … 1</td><td>M</td><td colspan="2"> von 1.2.40.0.34.6.0.11.1.15 Document Set Id and Version Number (DYNAMIC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:setId </td></tr></table></td><td>II</td><td>1 … 1</td><td>M</td><td>

<div>Eindeutige Id des Dokumentensets. Diese bleibt über alle Versionen der Dokumente gleich (initialer Wert bleibt erhalten). Die setId SOLL unterschiedlich zur clinicalDocument.id sein. ↔ Hinweis zum XDS-Mapping: Dieses Element wird ins XDS-Attribut referenceIdList

<div> XFRM - transformed: Das Dokument ist Ergebnis eines Transformationsprozesses, d.h. ist aus einem anderen Originaldokument hervorgegangen. </div>

<div>Hinweis: Die parallele Ablage von CDA-Dokumenten, welche vom Dokumentersteller bereits mit einem Stylesheet zu einem PDF Dokument gerendert wurden, kann mit der XFRM – Transaktion vorgenommen werden. Es ist nicht auszuschließen, dass die Transformation in lokalen Affinity Domains Anwendung findet. Für ELGA ist die Transformation jedoch kein Anwendungsfall.</div>

</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:parentDocument </td></tr></table></td><td></td><td>1 … 1</td><td>M</td><td>Vorhergehendes Dokument. </td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@classCode </td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">DOCCLIN</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@moodCode </td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:id </td></tr></table></td><td>II</td><td>1 … 1</td><td>M</td><td>Dokumenten-Id des vorgehenden Dokuments. <div>Grundsätzlich sind die Vorgaben für „Identifikations-Elemente“ zu befolgen. </div></td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td>1 … 1</td><td>M</td><td colspan="2"> von 1.2.40.0.34.6.0.11.1.7 Component Of - Encompassing Encounter (DYNAMIC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:componentOf </td></tr></table></td><td></td><td>1 … 1</td><td>M</td><td>Komponente für den Patientenkontakt. </td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="2">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">at-cda-bbr-dataelement-33</td><td style="vertical-align: top;" title="Headerelemente / ">[[File:Kyellow.png|14px]] Patientenkontakt </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] Dataset A Allgemeiner Leitfaden </td></tr></table></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@typeCode </td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:encompassingEncounter </td></tr></table></td><td></td><td>1 … 1</td><td>M</td><td>Patientenkontakt. </td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@classCode </td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">ENC</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@moodCode </td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:id </td></tr></table></td><td>II</td><td>0 … 1</td><td></td><td>Identifikationselement zur Aufnahme der Aufenthaltszahl </td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo [not(@nullFlavor)]</td><td></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="2">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">at-cda-bbr-dataelement-34</td><td style="vertical-align: top;" title="Headerelemente / Patientenkontakt / ">[[File:Kyellow.png|14px]] ID </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] Dataset A Allgemeiner Leitfaden </td></tr></table></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@extension </td></tr></table></td><td>st</td><td>1 … 1</td><td>R</td><td style="vertical-align: top;" colspan="2">Aufenthaltszahl, z.B.: Az123456 </td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@root </td></tr></table></td><td>uid</td><td>1 … 1</td><td>R</td><td style="vertical-align: top;" colspan="2">OID der Liste der Aufenthaltszahlen der Organisation </td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><ul>

<li>@assigningAuthorityName [0..1]: Name der Stelle, welche die ID zugewiesen hat, z.B.: „Amadeus Spital“.</li>

</ul>

</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:code </td></tr></table></td><td>CE</td><td>1 … 1</td><td>M</td><td>Codierung des Patientenkontakts. </td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="2">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">at-cda-bbr-dataelement-39</td><td style="vertical-align: top;" title="Headerelemente / Patientenkontakt / ">[[File:Kyellow.png|14px]] Art des Aufenthalts </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] Dataset A Allgemeiner Leitfaden </td></tr></table></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@code </td></tr></table></td><td>cs</td><td>1 … 1</td><td>R</td><td style="vertical-align: top;" colspan="2">Zulässige Werte gemäß Value-Set „ELGA_ActEncounterCode“ </td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@displayName </td></tr></table></td><td>st</td><td>0 … 1</td><td> </td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@codeSystem </td></tr></table></td><td>oid</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">2.16.840.1.113883.5.4</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@codeSystemName </td></tr></table></td><td>st</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">HL7:ActCode</td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 1.2.40.0.34.10.5 ELGA_ActEncounterCode (DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:effectiveTime </td></tr></table></td><td>IVL_TS</td><td>1 … 1</td><td>M</td><td><div>Zeitraum des Patientenkontakts.</div><div>Grundsätzlich sind die Vorgaben für „Zeit-Elemente“ zu befolgen. </div> Beinhaltet 1.2.40.0.34.6.0.11.9.15 Time Interval Information minimal (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="2">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">at-cda-bbr-dataelement-37</td><td style="vertical-align: top;" title="Headerelemente / Patientenkontakt / ">[[File:Kyellow.png|14px]] Beginn des Patientenkontaktes </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] Dataset A Allgemeiner Leitfaden </td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4">Der Zeitraum des Patientenkontaktes ~~muss~~ MUSS die Vorgaben der speziellen Implementierungsleitfäden einhalten. Dabei gilt allgemein: <ul><li>Der Zeitraum besteht aus dem Zeitpunkt der administrativen Aufnahme in die Behandlung und dem Zeitpunkt der administrativen Entlassung aus der Behandlung. </li><li>Der Entlassungszeitpunkt ~~kann~~KANN „unbekannt“ sein, wenn die administrative Entlassung noch nicht erfolgt ist. (nullFlavor UNK beim effectiveTime.high) </li><li>Hinweis: Als Zeitpunkt der Aufnahme/Entlassung SOLL der Zeitpunkt der administrativen Aufnahme/Entlassung angegeben werden. Wenn der Zeitpunkt der administrativen Aufnahme/Entlassung nicht vorhanden ist, darf auch der Zeitpunkt dermedizinischen Aufnahme/Entlassung angegeben werden. </li></ul></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:responsibleParty </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td><div>Komponente für die verantwortliche Person.</div></td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="2">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">at-cda-bbr-dataelement-40</td><td style="vertical-align: top;" title="Headerelemente / Patientenkontakt / ">[[File:Kyellow.png|14px]] Verantwortliche Person </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] Dataset A Allgemeiner Leitfaden </td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:assignedEntity </td></tr></table></td><td></td><td>1 … 1</td><td>M</td><td><div>Entität der verantwortlichen Person.</div><div>Grundsätzlich sind die Vorgaben für „AssignedEntity-Element (Person + Organisation)“ zu befolgen. </div>

</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td></td><td></td><td colspan="2"> von 1.2.40.0.34.6.0.11.9.22 Assigned Entity (DYNAMIC)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@classCode </td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">ASSIGNED</td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td>1 … *</td><td></td><td colspan="2"><div>

<div>Mindestens eine ID der Person der Entität</div>

<div>Organisationsdaten der Entität.</div>

<div>Grundsätzlich sind die Vorgaben gemäß „Organisations-Element“ zu befolgen.</div>

Beinhaltet 1.2.40.0.34.6.0.11.9.9 Organization Compilation with name (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td>1 … 1</td><td>M</td><td colspan="2"> von 1.2.40.0.34.6.0.11.1.8 Encounter Location (DYNAMIC) Die Organisation, in deren Verantwortungsbereich der Patientenkontakt stattfand, MUSS verpflichtend angegeben werden (z.B.: die entlassende Krankenanstalt mit Abteilung). </td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:location </td></tr></table></td><td></td><td>1 … 1</td><td>M</td><td></td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@typeCode </td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">LOC</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:healthCareFacility </td></tr></table></td><td></td><td>1 … 1</td><td>M</td><td></td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@classCode </td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">SDLOC</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:code </td></tr></table></td><td>CE</td><td>1 … 1</td><td>M</td><td>

<div>Der Code zur Klassifizierung des GDA repräsentiert die Art der Einrichtung, in der die Tätigkeit stattfand, die zur Erzeugung des Dokuments führte. Zum Beispiel sollten Dokumente, die während eines ambulanten Falls in einem Krankenhaus entstehen, mit dem healthcareFacilityTypeCode für „Krankenhaus“ gekennzeichnet werden. <div> </div></div>

<div>Zulässige Werte gemäß Value-Set „ELGA_HealthcareFacilityTypeCode“ <div>Für ELGA SOLL der Code dem Eintrag "GDA Rollenname" oder, wenn der GDA Rollenname nicht verfügbar ist, der "Aggregierten Rolle" im GDA-I entsprechen. </div><div> </div></div>

<div>Organisation, in deren Verantwortungsbereich der Patientenkontakt stattfand.</div>

Beinhaltet 1.2.40.0.34.6.0.11.9.9 Organization Compilation with name (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>1 … 1</td><td>M</td><td></td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@typeCode </td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@contextConductionInd </td></tr></table></td><td>bl</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">true</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:structuredBody </td></tr></table></td><td></td><td>1 … 1</td><td>M</td><td></td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@classCode </td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">DOCBODY</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@moodCode </td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:confidentialityCode </td></tr></table></td><td>CE</td><td>0 … 1</td><td></td><td></td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.16926 x_BasicConfidentialityKind (DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:languageCode </td></tr></table></td><td>CS</td><td>0 … 1</td><td></td><td></td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.69 Brieftext (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td>0 … 1</td><td></td><td colspan="2"><div>Sektion "Konsultations- oder Überweisungsgrund". Die Angabe dieser Sektion kann in unkodierter als auch in kodierter (mit entry) erfolgen.</div>Elemente in der Auswahl:<ul><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.17']] welches enthält Template 1.2.40.0.34.6.0.11.2.17 Konsultations- oder Überweisungsgrund - unkodiert (DYNAMIC)</li><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.47']] welches enthält Template 1.2.40.0.34.6.0.11.2.47 Konsultations- oder Überweisungsgrund - kodiert (DYNAMIC)</li></ul></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.17 Konsultations- oder Überweisungsgrund - unkodiert (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.17']]</td><td></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.47 Konsultations- oder Überweisungsgrund - kodiert (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.47']]</td><td></td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td>0 … 1</td><td></td><td colspan="2"><div>Die Angabe der bestehenden Medikation kann analog zur Patient Summary (kodiert) erfolgen. Hierbei ist aus jetziger Sicht noch zu beachten, dass templates der Patient Summary noch nicht in das neue ELGA Building Block Repository aufgenommen wurden. Daher wird sich die OID der kodierten Medikationsliste voraussichtlich noch ändern. Die Angabe der Medikationsliste kann auch in unkodierter Form erfolgen.</div>Elemente in der Auswahl:<ul><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.9']] welches enthält Template 1.2.40.0.34.6.0.11.2.9 Aktuelle Medikation - unkodiert (DYNAMIC)</li><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.63']] welches enthält Template 1.2.40.0.34.6.0.11.2.63 Medikationsliste PS - kodiert (DYNAMIC)</li></ul></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.9 Aktuelle Medikation - unkodiert (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.9']]</td><td></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.63 Medikationsliste PS - kodiert (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.63']]</td><td></td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td>0 … 1</td><td></td><td colspan="2">Elemente in der Auswahl:<ul><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.41']] welches enthält Template 1.2.40.0.34.6.0.11.2.41 Allergien und Intoleranzen - unkodiert (DYNAMIC)</li><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.59']] welches enthält Template 1.2.40.0.34.6.0.11.2.59 Allergien und Intoleranzen - kodiert (DYNAMIC)</li></ul></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.41 Allergien und Intoleranzen - unkodiert (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.41']]</td><td></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.59 Allergien und Intoleranzen - kodiert (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.59']]</td><td></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Die Sektion "Anamnese" kann unterschiedliche Sub-Sektionen enthalten. Diese Sub-Sektionen können kodiert oder unkodiert vorliegen. Sollten keine Sub-Sektionen verwendet werden, kann in dieser Sektion "Anamnese" nur unkodierter Inhalt verwendet werden, i.e. die Verwendung von entries ist NICHT erlaubt. Mögliche Sub-Sektionen umfassen: - Frühere Erkrankungen und Maßnahmen - Schwangerschaften - Medizinische Geräte und Implantate - Beeinträchtigungen - Impfungen - Lebensstil - Willenserklärungen und andere juridische Dokumente Beinhaltet 1.2.40.0.34.6.0.11.2.10 Anamnese (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td>0 … 1</td><td></td><td colspan="2"><div>Diese Sektion beinhaltet Angaben zu durchgeführten Befundungen und diagnostischen Maßnahmen Mögliche Sub-Sektionen sind: - Körperliche Untersuchung (z.B.: IPPAF) - Vitalparameter (z.B.: Körpermasse, Größe) - Fachspezifische Diagnostik (WICHTIG: Diese Sektion ist durch den vorliegenden Implementierungsleitfaden nicht spezifiziert. Erst durch fachspezifische Implementierungsleitfäden kann diese Sektion auch in kodierter Form geführt werden. - Ausstehende Befunde</div>Elemente in der Auswahl:<ul><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.11']] welches enthält Template 1.2.40.0.34.6.0.11.2.11 Status, Diagnostik und Befunde - unkodiert (DYNAMIC)</li><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.57']] welches enthält Template 1.2.40.0.34.6.0.11.2.57 Status, Diagnostik und Befunde - kodiert (DYNAMIC)</li></ul></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.11 Status, Diagnostik und Befunde - unkodiert (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.11']]</td><td></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.57 Status, Diagnostik und Befunde - kodiert (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.57']]</td><td></td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td>0 … 1</td><td></td><td colspan="2"><div>Diese Sektion beinhaltet Angaben zu erhobenen Diagnosen.</div>Elemente in der Auswahl:<ul><li>hl7:component welches enthält Template 1.2.40.0.34.6.0.11.2.83 Diagnose - unkodiert (DYNAMIC)</li><li>hl7:component welches enthält Template 1.2.40.0.34.6.0.11.2.96 Diagnose - kodiert (DYNAMIC)</li></ul></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.83 Diagnose - unkodiert (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.96 Diagnose - kodiert (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Die Sektion "Verlauf" beschreibt in narrativer Form den Krankheits- bzw. Problemverlauf. Beinhaltet 1.2.40.0.34.6.0.11.2.12 Verlauf (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.25 Zusammenfassende Beurteilung (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td>0 … 1</td><td></td><td colspan="2"><div>Die Angaben in der Sektion "Durchgeführte Maßnahmen" können kodiert oder unkodiert erfolgen. Als mögliche Sub-Sektion kann "Pflegemaßnahmen" angeführt werden. </div>Elemente in der Auswahl:<ul><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.22']] welches enthält Template 1.2.40.0.34.6.0.11.2.22 Durchgeführte Maßnahmen - unkodiert (DYNAMIC)</li><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.13']] welches enthält Template 1.2.40.0.34.6.0.11.2.13 Durchgeführte Maßnahmen - kodiert (DYNAMIC)</li></ul></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.22 Durchgeführte Maßnahmen - unkodiert (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.22']]</td><td></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.13 Durchgeführte Maßnahmen - kodiert (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.13']]</td><td></td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td>0 … 1</td><td></td><td colspan="2"><div>Die Sektion "Empfohlene Medikation" führt die durch den ambulanten Besuch verordnete Medikation. WICHTIG: sollte es durch den ambulanten Besuch zu Änderungen der bestehenden Medikation kommen MUSS sichergestellt werden, dass dies auch im section/text ersichtlich ist. Hierbei ist eine textuelle Hervorhebung empfohlenen. Für den Fall, dass diese Sektion kodiert angeführt wird MUSS darauf geachtet werden, dass die effectiveTime-Elemente darstellen ab wann/bzw. seit wann eine medikamentöse Therapie verordnet wurde.</div>Elemente in der Auswahl:<ul><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.56']] welches enthält Template 1.2.40.0.34.6.0.11.2.56 Empfohlene Medikation - unkodiert (DYNAMIC)</li><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.21']] welches enthält Template 1.2.40.0.34.6.0.11.2.21 Empfohlene Medikation - kodiert (DYNAMIC)</li></ul></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.56 Empfohlene Medikation - unkodiert (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.56']]</td><td></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.21 Empfohlene Medikation - kodiert (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.21']]</td><td></td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td>0 … 1</td><td></td><td colspan="2"><div>Diese Sektion kann folgende Sub-Sektionen beinhalten: - Termine, Kontrollen, Wiederbestellung - Empfohlene Anordnungen Pflege - Geplante Untersuchungen - Konservative Therapie - Chirurgische Therapie Sollte keine Sub-Sektion verwendet werden, können die Angaben in dieser Sektion nur unkodiert geführt werden.</div>Elemente in der Auswahl:<ul><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.23']] welches enthält Template 1.2.40.0.34.6.0.11.2.23 Weitere empfohlene Maßnahmen - unkodiert (DYNAMIC)</li><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.58']] welches enthält Template 1.2.40.0.34.6.0.11.2.58 Weitere empfohlene Maßnahmen - kodiert (DYNAMIC)</li></ul></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.23 Weitere empfohlene Maßnahmen - unkodiert (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.23']]</td><td></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.58 Weitere empfohlene Maßnahmen - kodiert (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.58']]</td><td></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.26 Weitere Informationen (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.61 Willenserklärungen und andere juridische Dokumente (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.70 Abschließende Bemerkung (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:component </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>In dieser Sektion können Beilagen (in XML-embedded) angehängt werden. Beinhaltet 1.2.40.0.34.6.0.11.2.71 Beilagen (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...und)</td></tr></table></td></tr></table>

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