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Template FAST Befunde 2017‑02‑21

Id1.2.276.0.76.10.4105
ref
aktin-
Effective Date2017‑02‑21
Statusdraft DraftVersion Label
NameFASTfindingsDisplay NameFAST Befunde
DescriptionFAST Befunde (Focused assessment with ultrasonography for trauma)
ContextParent nodes of template element with id 1.2.276.0.76.10.4105
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 2 templates, Uses 1 template
Used by as NameVersion
1.2.276.0.76.10.4097Containmentdraft PreHospital Encounter Entry2017‑02‑01
1.2.276.0.76.10.4136Containmentdraft Inpatient Hospital Encounter Detail Observation Organizer2017‑02‑01
Uses as NameVersion
1.2.276.0.76.10.4134Containmentdraft FAST Befunde freie FlüssigkeitDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
Example
FAST Befund, nur narrativ (in section.text)
<observation classCode="OBS" moodCode="EVN">
  <templateId root="1.2.276.0.76.10.4105"/>  <id root="1.2.276.0.76.4.17.9814184919" extension="ac9eb111-93b0-4c84-8e55-98f2098b7950"/>  <code code="X-FAST" codeSystem="2.16.840.1.113883.6.1" displayName="Focused assessment with ultrasonography for trauma"/>  <statusCode code="completed"/>  <effectiveTime value="20171219"/>  <value xsi:type="CE" nullFlavor="OTH">
    <originalText>
      <reference value="#fast"/>    </originalText>  </value></observation>
Example
FAST Befund, codiert als ohne path. Befund, mit zusätzlichem freien Text (in section.text)
<observation classCode="OBS" moodCode="EVN">
  <templateId root="1.2.276.0.76.10.4105"/>  <id root="1.2.276.0.76.4.17.9814184919" extension="ac9eb111-93b0-4c84-8e55-98f2098b7950"/>  <code code="X-FAST" codeSystem="2.16.840.1.113883.6.1" displayName="Focused assessment with ultrasonography for trauma"/>  <statusCode code="completed"/>  <effectiveTime value="20171219"/>  <value xsi:type="CE" code="OPB" codeSystem="1.2.276.0.76.3.1.195.5.51" displayName="ohne path. Befund">
    <originalText>
      <reference value="#fast"/>    </originalText>  </value></observation>
Example
FAST Befund, codiert mit path. Befund und Text (in section.text), freie Flüssigkeit beobachtet
<observation classCode="OBS" moodCode="EVN">
  <templateId root="1.2.276.0.76.10.4105"/>  <id root="1.2.276.0.76.4.17.9814184919" extension="ac9eb111-93b0-4c84-8e55-98f2098b7950"/>  <code code="X-FAST" codeSystem="2.16.840.1.113883.6.1" displayName="Focused assessment with ultrasonography for trauma"/>  <statusCode code="completed"/>  <effectiveTime value="20171219"/>  <value xsi:type="CE" code="PB" codeSystem="1.2.276.0.76.3.1.195.5.51" displayName="path. Befund">
    <originalText>
      <reference value="#fast"/>    </originalText>  </value>  <entryRelationship typeCode="COMP">
    <!-- FAST: Freie Flüssigkeit 1.2.276.0.76.10.4134 -->
  </entryRelationship></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
1 … 1FASTdotsings
@classCode
cs1 … 1FOBS
@moodCode
cs1 … 1FEVN
hl7:templateId
II1 … 1FASTdotsings
@root
uid1 … 1F1.2.276.0.76.10.4105
hl7:id
II1 … 1FASTdotsings
hl7:code
CE1 … 1MFASTdotsings
@code
CONF1 … 1FX-FAST
@codeSystem
1 … 1F2.16.840.1.113883.6.1
hl7:text
ED0 … 1de-DE Lediglich reference in den Text der zugehörigen SectionFASTdotsings
hl7:reference
URL1 … 1FASTdotsings
hl7:statusCode
CS1 … 1MFASTdotsings
@code
CONF1 … 1Fcompleted
hl7:effectiveTime
TS0 … 1de-DE Zeitpunkt der UntersuchungFASTdotsings
Choice … 1Elements to choose from:
  • hl7:value[@nullFlavor]
  • hl7:value[@code]
hl7:value
CE … 1Rde-DE Freitexlicher Befund (in section.text), kein CodeFASTdotsings
where [@nullFlavor]
@nullFlavor
cs1 … 1FOTH
hl7:originalText
ED0 … 1Rde-DE Lediglich reference in den Text der zugehörigen SectionFASTdotsings
hl7:reference
URL1 … 1FASTdotsings
hl7:value
CE … 1Rde-DE Codierter Befund mit zusätzlichem freien Text (in section.text)FASTdotsings
where [@code]
 CONF
The value of @code shall be drawn from value set 1.2.276.0.76.11.51 Finding situation (DYNAMIC)
hl7:originalText
ED0 … 1Rde-DE zusätzlicher freier Text, lediglich reference in den Text der zugehörigen SectionFASTdotsings
hl7:reference
URL1 … 1FASTdotsings
hl7:entryRelationship
0 … 1Rde-DE FAST: freie Flüssigkeit
Contains 1.2.276.0.76.10.4134 FAST Befunde freie Flüssigkeit (DYNAMIC)		FASTdotsings
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl0 … 1Ftrue