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2.16.840.1.113883.2.16.777.5.10.11/static-2018-10-18T143423

231 Bytes hinzugefügt, 13:54, 28. Nov. 2020

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Multidisziplinäre Befunde: Der CDA-Standard in Release 2.0 erlaubt nur die Angabe eines legalAuthenticator-Elements, es können jedoch beliebig viele (Mit-) Unterzeichner angegeben werden, siehe „Weitere Unterzeichner („authenticator“)“. Wenn kein eindeutiger Hauptunterzeichner ermittelt werden kann (z.B. bei multidisziplinären Befunden, die von mehreren Fachärzten mit unterschiedlicher Fachrichtung gleichermaßen verantwortet werden), kann die Angabe des Hauptunterzeichners entfallen, wenn mindestens zwei Mitunterzeichner angegeben werden.

Automatisch erstellte Befunde: Bei Dokumenten, die von „Geräten“ erstellt wurden (wenn der Inhalt durch einen Algorithmus erzeugt und nicht von einer natürlichen Person freigegeben wurde), entfällt die Angabe aller Unterzeichner.</div></td></tr></table></td><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Header 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">Offen (auch andere als die definierten 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 class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Benutzt 1 Template</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" 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;">1.2.40.0.34.11.90003</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] AssignedEntityElements</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beziehung</th><td style="text-align: left;" colspan="3">Spezialisierung: Template 1.2.40.0.34.11.20006 HeaderLegalAuthenticator (2011‑12‑19) <div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">elgabbr-</div> Version: Template 1.2.40.0.34.11.20006 HeaderLegalAuthenticator (2011‑12‑19) <div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">elgabbr-</div></td></tr><tr class="explabel " style="vertical-align: top;"><td style="width: 20em; text-align: left;">Beispiel</td><td colspan="3" class="explabelblue"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable">Strukturbeispiel</td></tr><tr><td><legalAuthenticator>  <time value="20130324082015+0100"/>  <signatureCode code="S"/>  <assignedEntity>  <id root="1.2.40.0.34.99.111.1.3" extension="2222" assigningAuthorityName="Amadeus Spital"/>  <telecom use="WP" value="tel:+43.6138.3453446.2222"/>  <assignedPerson>  <name> <prefix>Univ.-Prof.Dr.</prefix> <given>Sigrid</given> <family>Kollmann</family> </name> </assignedPerson>  <representedOrganization> <id root="1.2.40.0.34.99.3" assigningAuthorityName="GDA Index"/> <name>Amadeus Spital - Chirurgische Abteilung</name> <telecom value="tel:+43.6138.3453446.0"/> <telecom value="fax:+43.6138.3453446.4674"/> <telecom value="mailto:info@amadeusspital.at"/> <telecom value="http://www.amadeusspital.at"/> <addr> <streetName>Mozartgasse</streetName> <houseNumber>1-7</houseNumber> <postalCode>5350</postalCode> <city>St.Wolfgang</city> <state>Salzburg</state> <country>AUT</country> </addr> </representedOrganization> </assignedEntity></legalAuthenticator></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" 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 class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td>hl7:legalAuthenticator </td></tr></table></td><td></td><td></td><td></td><td>Rechtlicher Unterzeichner. </td><td style="background-color: #FFEEEE;">(Hea...tor)</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><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">LA</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:time </td></tr></table></td><td>TS.DATE.MIN</td><td>1 … 1</td><td>R</td><td><div>Der Zeitpunkt, an dem das Dokument unterzeichnet wurde.</div>

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

<div>

</div>

<div>Zugelassene nullFlavor: UNK

</div></td><td style="background-color: #FFEEEE;">(Hea...tor)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:signatureCode </td></tr></table></td><td>CS</td><td>1 … 1</td><td>M</td><td>Signaturcode gibt an, dass das Originaldokument unterzeichnet wurde. </td><td style="background-color: #FFEEEE;">(Hea...tor)</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><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="1" class="conf">CONF</td><td>1 … 1</td><td>F</td><td colspan="2">S</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><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>Personendaten des rechtlichen Unterzeichners.</div>

<div>

</div>

<div>Grundsätzlich sind die Vorgaben gemäß Kapitel „AssignedEntity-Element (Person + Organisation)“ zu befolgen.

</div></td><td style="background-color: #FFEEEE;">(Hea...tor)</td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td></td><td></td><td colspan="2"> von 1.2.40.0.34.11.90003 AssignedEntityElements (DYNAMIC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><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 … *</td><td>R</td><td><div>Mindestens eine Id der validierenden Person.</div><div>Zugelassene nullFlavor: UNK</div></td><td style="background-color: #FFEEEE;">(Hea...tor)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:addr </td></tr></table></td><td>AD</td><td>0 … 1</td><td></td><td><div>Ein Adress-Element der validierenden Person.</div><div>Zugelassene nullFlavor: UNK</div></td><td style="background-color: #FFEEEE;">(Hea...tor)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:telecom </td></tr></table></td><td>TEL.AT</td><td>0 … *</td><td></td><td><div>Mindestens ein Telecom-Element der validierenden Person.</div><div>Zugelassene nullFlavor: UNK</div></td><td style="background-color: #FFEEEE;">(Hea...tor)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:assignedPerson </td></tr></table></td><td></td><td>1 … 1</td><td>M</td><td>Persondendaten der validierenden Person.</td><td style="background-color: #FFEEEE;">(Hea...tor)</td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td></td><td></td><td colspan="2"> von 1.2.40.0.34.11.90001 PersonElements (DYNAMIC)</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><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">PSN</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><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>@determinerCode </td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">INSTANCE</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><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:name </td></tr></table></td><td>PN</td><td>1 … 1</td><td>M</td><td>Name der PersonFür den Namen ist verpflichtend Granularitätsstufe 2 („strukturierte Angabe des Namens‘‘) anzuwenden! Grundsätzlich sind die Vorgaben für „Namen-Elemente von Personen PN“ zu befolgen.</td><td style="background-color: #FFEEEE;">(Hea...tor)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:representedOrganization </td></tr></table></td><td></td><td>0 … 1</td><td></td><td>Organistationsdaten der validierenden Person.</td><td style="background-color: #FFEEEE;">(Hea...tor)</td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td></td><td></td><td colspan="2"> von 1.2.40.0.34.11.90002 OrganizationElements (DYNAMIC)</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><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></td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">ORG</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><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>@determinerCode </td></tr></table></td><td></td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">INSTANCE</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><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 … *</td><td></td><td></td><td style="background-color: #FFEEEE;">(Hea...tor)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><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:name </td></tr></table></td><td>ON</td><td>1 … 1</td><td>M</td><td></td><td style="background-color: #FFEEEE;">(Hea...tor)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><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:telecom </td></tr></table></td><td>TEL.AT</td><td>0 … *</td><td></td><td></td><td style="background-color: #FFEEEE;">(Hea...tor)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><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:addr </td></tr></table></td><td>AD</td><td>0 … 1</td><td></td><td></td><td style="background-color: #FFEEEE;">(Hea...tor)</td></tr></table></td></tr></table>

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