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1.2.40.0.34.6.0.11.2.84/static-2024-02-27T101120

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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;">1.2.40.0.34.6.0.11.2.84</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2024‑02‑27 10:11:20</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;">1.0.0</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">elgabgd_section_DurchgefuehrteUntersuchung</td><th style="width: 20em; text-align: left;">Bezeichnung</th><td style="text-align: left;">Durchgeführte Untersuchung</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><div>

Eine Kurzbeschreibung sämtlicher zur Erstellung des Befundes angewandten Techniken, Eingriffe oder sonstige Maßnahmen ist für alle Modalitäten optional.

Die Dokumentation der Patientendosis für Computertomographie-, Radiologie-, Nuklearmedizinische Befunde gemäß der Strahlenschutzrichtlinie 2013/59/EU Art. 58b SOLL in dieser Sektion erfolgen. Der Befund MUSS dann die Informationen zur Ermittlung der Patientendosis beinhalten und die Dosisparameter sind mindestens in Level 2 darzustellen.

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</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">Elternknoten des Template-Element mit Id 1.2.40.0.34.6.0.11.2.84</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Section 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 6 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;">1.2.40.0.34.6.0.11.9.36</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Author Body (1.0.1+20230717)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.3</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Informant Body (1.0.1+20211213)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.183</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Strahlenexposition Entry (1.0.0)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.184</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Radiopharmakon Entry (1.0.0)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.19</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Eingebettetes Objekt Entry (1.0.2+20230717)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.8</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Übersetzung (1.0.2+20230717)</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></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="explabelblue"><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">Strukturbeispiel (ohne Level 3)</td></tr><tr><td><section> <templateId root="1.2.40.0.34.6.0.11.2.84"/>  <code code="55111-9" displayName="Current imaging procedure descriptions" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <title>Durchgeführte Untersuchung</title>  <text> ... Lesbarer Textbereich ... </text></section></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="explabelblue"><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">Strukturbeispiel Aufnahme der Patientendosis</td></tr><tr><td><section> <templateId root="1.2.40.0.34.6.0.11.2.84"/>  <code code="55111-9" displayName="Current imaging procedure descriptions" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <title>Durchgeführte Untersuchung</title>  <text> ... Lesbarer Textbereich ... <paragraph> Informationen zur Patientendosis </paragraph> <table> <thead> <tr> <th>Parameter</th> <th>Ergebnis</th> <th>Einheit</th> </tr> </thead> <tbody> <tr ID="OBS-1"> <td>Dosislängenprodukt</td> <td>230</td> <td>mGycm</td> </tr> <tr ID="OBS-2"> <td>Effektive Dosis</td> <td>2.5</td> <td>mSv</td> </tr> </tbody> </table> </text>   <entry typeCode="DRIV">  <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.14"/> <templateId root="1.2.40.0.34.6.0.11.3.183"/> <code code="113813" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="CT Dose Length Product Total"/> <text> <reference value="#OBS-1"/> </text> <statusCode code="completed"/> <effectiveTime value="20130823073406+0200"/> <value xsi:type="PQ" value="230" unit="mGy.cm"/> </observation> </entry> <entry typeCode="DRIV">  <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.14"/> <templateId root="1.2.40.0.34.6.0.11.3.183"/> <code code="113839" codeSystem="1.2.840.10008.2.16.4" codeSystemName="DCM" displayName="Effective Dose"/> <text> <reference value="#OBS-2"/> </text> <statusCode code="completed"/> <effectiveTime value="20130823073406+0200"/> <value xsi:type="PQ" value="2.5" unit="mSv"/> </observation> </entry></section></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:section </td></tr></table></td><td></td><td></td><td></td><td></td><td style="background-color: #FFEEEE;">(elg...ung)</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">DOCSECT</td></tr><tr style="vertical-align: top; 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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></td><td style="background-color: #FFEEEE;">(elg...ung)</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">55111-9</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">Current imaging procedure descriptions</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></td><td style="background-color: #FFEEEE;">(elg...ung)</td></tr><tr style="vertical-align: top; background-color: #FFEEEE;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4" style="background-color: white;"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>Elementinhalt muss "Durchgeführte Untersuchung" sein</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:text </td></tr></table></td><td>ED</td><td>1 … 1</td><td>M</td><td>Der Befundtext sollte in Abschnitte ( <paragraph>) gegliedert sein. Vorgegebene Struktur für die Angaben zur Patientendosis über das medizinisch-radiologische Verfahren: Die effektive Dosis oder Parameter zur Patientendosis MÜSSEN im Textteil als Tabelle enthalten sein.</paragraph>

</td><td style="background-color: #FFEEEE;">(elg...ung)</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:author </td></tr></table></td><td></td><td>0 … *</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.9.36 Author Body (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...ung)</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:informant </td></tr></table></td><td></td><td>0 … *</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.9.3 Informant Body (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...ung)</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:entry </td></tr></table></td><td></td><td>0 … *</td><td></td><td><div>Im Falle eines Befundes für Röntgenaufnahmen, Computertomographie, Durchleuchtung, Interventionelle Radiologie oder Mammographie: Unabhängig von der Modalität zur Codierung des Dosisparameters nach DCM in Level 3.</div> Beinhaltet 1.2.40.0.34.6.0.11.3.183 Strahlenexposition Entry (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...ung)</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:entry </td></tr></table></td><td></td><td>0 … *</td><td></td><td><div>Im Falle eines Befundes der Nuklearmedizin: Codierung des applizierten Radiopharmakons.</div> Beinhaltet 1.2.40.0.34.6.0.11.3.184 Radiopharmakon Entry (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...ung)</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:entry </td></tr></table></td><td></td><td>0 … *</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.3.19 Eingebettetes Objekt Entry (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...ung)</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>0 … *</td><td></td><td>Optionale Subsections zur Angabe von Übersetzungen des text-Elements in andere Sprachen. Beinhaltet 1.2.40.0.34.6.0.11.2.8 Übersetzung (DYNAMIC)</td><td style="background-color: #FFEEEE;">(elg...ung)</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>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">true</td></tr></table></td></tr></table>

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