Änderungen

<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;">1.2.40.0.34.6.0.11.1.48</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2020‑08‑26 15:29:24</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] Entwurf</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;">atlab_header_DocumentationOfServiceEventLaborMikrobiologie</td><th style="width: 20em; text-align: left;">Bezeichnung</th><td style="text-align: left;">Documentation Of Service Event - Labor- und Mikrobiologie</td></tr><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><p class="MsoNormal"> <span lang="DE-AT" style="background-image: initial; background-position: initial; background-size: initial; background-repeat: initial; background-attachment: initial; background-origin: initial; background-clip: initial;">Dokumentation der wesentlichen <b>Untersuchungsinhalte des Laborbefundes</b>.Die entsprechenden Codes sind in dem </span> <span lang="DE-AT">hierarchischen</span> <span lang="DE-AT" style="background-image: initial; background-position: initial; background-size: initial; background-repeat: initial; background-attachment: initial; background-origin: initial; background-clip: initial;"> V</span> <span lang="DE-AT">alue Set „<span style="font-variant-numeric: inherit; font-variant-east-asian: inherit; font-stretch: inherit; line-height: inherit;"> <b>ELGA_ServiceEventsLabor<br /b> </span>“ </span> <span lang="DE-AT" style="background-image: initial; background-position: initial; background-size: initial; background-repeat: initial; background-attachment: initial; background-origin: initial; background-clip: initial;">zufinden, wobei </span> <span lang="DE-AT">in den ServiceEvents nur die Codes der <b>obersten</b> Ebene kodiert werden (</span>z.B.: Laborauftrag 26515-7 „Thrombozyten“ wird mit 300 „Hämatologie“ kodiert).</p> <p class="MsoNormal"> <span lang="DE-AT">Der <b>Mikrobiologiebefund </b>ist in den ServiceEvents zusätzlich mit dem Code 18725-2 (Microbiology studies) anzugeben. </span>Ein Befund kann als Mikrobiologiebefund angegeben werden, wenn eine oder mehrere der Sektionen Bakteriologie, Kultureller Erregernachweis, Antibiogramm, Minimale Hemmkonzentration oder Molekularer Erregernachweis enthalten sind.<br /p>

<ul> <li>Es <b>SOLL mindestens eine Gesundheitsdienstleistung</b> als documentationOf/serviceEvent-Element angegeben werden</li> <li>Es <b>können beliebig viele</b> weitere Gesundheitsdienstleistungen als weitere documentationOf/serviceEvent-Elemente angegeben werden</li> <li>Die Zeitangaben des <b>ersten </b>documentationOf/serviceEvent-Elements werden in die Dokument-Metadaten übernommen</li> <li>Die serviceEvents sind die einzigen medizinischen Informationen zum Dokument im XDS-Dokumentenregister. Sie können daher als <b>Such-/Filterkriterium</b> verwendet werden und scheinen ggf. in den Ergebnissen der Suchabfragen auf</li></ul><div> <ul>  </ul></div> </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">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 2 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;">1.2.40.0.34.6.0.11.9.15</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Time Interval Information minimal (2020)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.91.2241</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Assigned Entity Performer Header - Laboratory (2020)</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">Adaptation: Template 1.2.40.0.34.6.0.11.1.17 <i>Documentation Of Service Event </i> (2019‑03‑14 15:08:34) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</div></span></td></tr><tr class="explabel " style="vertical-align: top;"><th class="" style="width: 20em; text-align: left;">Beispiel</th><td colspan="3" class="explabelgreen"><table width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Strukturbeispiel Koloskopie</span></td></tr><tr><td><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">documentationOf</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">DOC</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">serviceEvent</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">ACT</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">KOL</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Koloskopie</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.2.3.4.5.6.7.8.9</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">Name des Codesystems</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20190611102209+0200</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">high</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20190611132209+0200</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">performer</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">PRF</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">assignedEntity</span><span class="ppsign">&gt;</span><br /><span style="display: block;">        <span style="color:green">&lt;!-- include template 1.2.40.0.34.6.0.11.9.22 'Assigned Entity' (dynamic) 1..1 M --&gt;<br /></span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">assignedEntity</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">performer</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">serviceEvent</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">documentationOf</span><span class="ppsign">&gt;</span></span></span></td></tr></table></td></tr><tr class="explabel " style="vertical-align: top;"><th class="" style="width: 20em; text-align: left;">Beispiel</th><td colspan="3" class="explabelgreen"><table width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Strukturbeispiel Hämatologie</span></td></tr><tr><td><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">documentationOf</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">DOC</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">serviceEvent</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">ACT</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">300</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Hämatologie</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.5.11</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">ELGA_LaborparameterErgaenzung</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20190611102209+0200</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">high</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20190611132209+0200</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">performer</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">PRF</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">time</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppelement">low</span> <span class="ppattribute">nullFlavor</span><span class="ppsign">="</span><span class="ppcontent">UNK</span><span class="ppsign">"</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20190611132209+02:00</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppelement">high</span> <span class="ppattribute">nullFlavor</span><span class="ppsign">="</span><span class="ppcontent">UNK</span><span class="ppsign">"</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20190611132209+02:00</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">time</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">assignedEntity</span><span class="ppsign">&gt;</span><br /><span style="display: block;">        <span style="color:green">&lt;!-- include template 1.2.40.0.34.6.0.11.9.22 'Assigned Entity' (dynamic) 1..1 M --&gt;<br /></span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">assignedEntity</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">performer</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">serviceEvent</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">documentationOf</span><span class="ppsign">&gt;</span></span></span></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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:documentationOf<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Komponente für die Gesundheitsdienstleistung.<br />

<br />Der Wert von @code muss gewählt werden aus dem Value dem <span lang="DE-AT">hierarchischen</span> Value Set 1.2.40.0.34.10.22 <span style="font-variant-numeric: inherit; font-variant-east-asian: inherit; font-stretch: inherit; line-height: inherit;"> <b>ELGA_ServiceEventsLabor</b></span> gewählt werden<span lang="DE-AT" style="background-image: initial; background-position: initial; background-size: initial; background-repeat: initial; background-attachment: initial; background-origin: initial; background-clip: initial;">, wobei</span> <span lang="DE-AT">in den ServiceEvents nur die Codes der <b>obersten Ebene</b> kodiert werden (</span>z.B.: Laborauftrag 26515-7 „Thrombozyten" wird mit 300 „Hämatologie" kodiert).<p class="MsoNormal"> <span lang="DE-AT">Der <b>Mikrobiologiebefund</b> ist in den ServiceEvents zusätzlich mit dem Code <b>18725-2</b> (Microbiology studies) anzugeben. <br /span> Ein Befund kann als Mikrobiologiebefund angegeben werden, wenn eine oder mehrere der Sektionen Bakteriologie, Kultureller Erregernachweis, Antibiogramm, Minimale Hemmkonzentration oder Molekularer Erregernachweis enthalten sind.<br /p>

</td><td style="background-color: #FFEEEE;"><span title="">(atl...gie)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo <i> [not(@nullFlavor)]</i></td><td></td></tr><tr><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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2"></td></tr><tr><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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@codeSystem<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>oid</td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2"></td></tr><tr><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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@displayName<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>st</td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2">TODO: required?</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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:effectiveTime<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>IVL_TS</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td>Zeitraum der Gesundheitsdienstleistung.<br />Die semantische Bedeutung dieser Zeitpunkte wird in den speziellen Implementierungsleitfäden festgelegtAngabe des zeitlichen Erbringungsintervalls effectiveTime mit einer Start- low und Endzeit high (verpflichtend). <br />

<li>serviceStartTime: Beginn des ersten documentationOf/serviceEvent-Elements</li> <li>serviceStopTime: Ende des ersten documentationOf/serviceEvent-Elements </li> </ul>