elga-cdalab-2.06.2:Überblick
Überblick
| Feld | Element | Opt | Kapitel |
|---|---|---|---|
| Daten zum Dokument | |||
| Realm Code | ClinicalDocument/realmCode | M | Link |
| Dokumentenformat | ClinicalDocument/typeId | M | Link |
| Dokumenten-ID | ClinicalDocument/id | M | Link |
| Vertraulichkeitscode | ClinicalDocument/confidentialityCode | M | Link |
| Sprachcode | ClinicalDocument/languageCode | M | Link |
| Template | ClinicalDocument/templateId | M | Link |
| Dokumenttitel | ClinicalDocument/title | M | Link |
| Dokumentenklasse | ClinicalDocument/code | M | Link |
| Dokumentdatum | ClinicalDocument/effectiveTime | M | Link |
| Versionierung des Dokuments | ClinicalDocument/setId ClinicalDocument/versionNumber |
M | Link |
| Teilnehmende Parteien | |||
| Patient | ClinicalDocument/recordTarget | M | Link |
| Verwalter des originalen Dokuments | ClinicalDocument/custodian | M | Link |
| Rechtlicher Unterzeichner | ClinicalDocument/legalAuthenticator | M [1..1] |
Link |
| Verfasser des Dokuments | ClinicalDocument/author | M [1..*] |
Link |
| Vorgesehener Empfänger | ClinicalDocument/informationRecipient | O [0..*] |
Link |
| Validatoren | ClinicalDocument/authenticator | O [0..*] |
Link |
| Referenz zum Auftrag | |||
| Auftraggeber (IHE „Ordering Provider“) | ClinicalDocument/participant@typeCode=“REF“ | R [1..1] |
Link |
| Auftragsidentifikation | ClinicalDocument/inFulfillmentOf/order | M [1..1] |
Link |
| Dokumentation der Gesundheitsdienstleistung | |||
| Service Events | ClinicalDocument/documentationOf/serviceEvent | M [1..*] |
Link |
| Durchführende Labors | ClinicalDocument/documentationOf/serviceEvent/performer | O [0..*] |
Link |
| Informationen zum Patientenkontakt | |||
| Encounter | ClinicalDocument/componentOf/encompassingEncounter | O [0..1] |
Link |
Tabelle 2: Überblick administrative Daten (Header)
