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Template Befundtext (Anmerkungen und Kommentare) 2015‑01‑30

Id1.2.40.0.34.11.4.3.2
ref
elgabbr-
Effective Date2015‑01‑30
Statusactive ActiveVersion Label
NameAnnotationDisplay NameBefundtext (Anmerkungen und Kommentare)
ContextParent nodes of template element with id 1.2.40.0.34.11.4.3.2
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 23 templates, Uses 0 templates
Used by as NameVersion
1.2.40.0.34.11.4.2.2Containmentretired Bereichsübergreifende Befundbewertung (Laboratory Report Comment Section)2012‑01‑07
1.2.40.0.34.11.4.2.2Containmentactive Bereichsübergreifende Befundbewertung (Laboratory Report Comment Section)2013‑02‑10
1.2.40.0.34.11.30020Containmentretired ELGA Spezimen-Act-Entry Allgemein2012‑01‑07
1.2.40.0.34.11.30020Containmentretired ELGA Spezimen-Act-Entry Allgemein2014‑03‑04
1.2.40.0.34.11.30020Containmentretired ELGA Spezimen-Act-Entry Allgemein2015‑04‑30
1.2.40.0.34.11.30020Containmentretired ELGA Spezimen-Act-Entry Allgemein2017‑02‑20
1.2.40.0.34.11.30020Containmentdraft ELGA Spezimen-Act-Entry Allgemein2017‑02‑22
1.2.40.0.34.11.30022Containmentactive Annahmeinformationen (Specimen Received)2014‑03‑04
1.2.40.0.34.11.30023Includeretired Befundgruppen (Laboratory Battery Organizer)-deprecated2012‑01‑07
1.2.40.0.34.777.10.10.997Containmentcancelled Laborergebnisse (Laboratory Observation)2020‑04‑15 19:37:02
1.2.40.0.34.777.10.10.998Containmentcancelled Befundgruppen (Laboratory Battery Organizer)2020‑04‑15 19:35:19
1.3.6.1.4.1.19376.1.3.1.4Containmentretired Befundgruppen (Laboratory Battery Organizer)2013‑09‑09
1.3.6.1.4.1.19376.1.3.1.4Containmentdraft Befundgruppen (Laboratory Battery Organizer)2017‑02‑23
1.3.6.1.4.1.19376.1.3.1.6Containmentretired Laborergebnisse (Laboratory Observation)2013‑11‑07
1.3.6.1.4.1.19376.1.3.1.6Containmentretired Laborergebnisse (Laboratory Observation)2014‑03‑04
1.3.6.1.4.1.19376.1.3.1.6Containmentretired Laborergebnisse (Laboratory Observation)2014‑12‑06
1.3.6.1.4.1.19376.1.3.1.6Containmentactive Laborergebnisse (Laboratory Observation)2015‑03‑26
1.3.6.1.4.1.19376.1.3.1.6Containmentdraft Laborergebnisse (Laboratory Observation)2020‑06‑15 08:50:28
2.16.840.1.113883.3.1937.99.61.19.10.22Containmentdraft Laborergebnisse (Laboratory Observation)2017‑05‑10 18:55:56
2.16.840.1.113883.3.1937.99.61.41.10.16Containmentdraft Annahmeinformationen (Specimen Received)-Sandbox-sm2019‑03‑26 18:02:35
2.16.840.1.113883.3.1937.99.61.41.10.18Containmentdraft Befundgruppen (Laboratory Battery Organizer)-Sandbox-sm2019‑03‑26 18:07:27
2.16.840.1.113883.3.1937.777.24.10.43Containmentdraft Befundgruppen (Laboratory Battery Organizer)B2019‑03‑15 14:41:04
2.16.840.1.113883.3.1937.777.24.10.48Containmentdraft ELGA Spezimen-Act-Entry AllgemeinA2019‑03‑26 15:44:14
RelationshipVersion: template 1.2.40.0.34.11.4.3.2 Befundtext (Anmerkungen und Kommentare) (2015‑01‑30)
ref
elgabbr-
Example
Strukturbeispiel
<act classCode="ACT" moodCode="EVN">
  <templateId root="1.2.40.0.34.11.4.3.2"/>  <templateId root="2.16.840.1.113883.10.20.1.40"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.2"/>  <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation Comment"/>  <text>
    <reference value="#commonRemark1"/>  </text>  <statusCode code="completed"/></act>
Example
Kommentar zu einer Analyse
<!--Die Einbindung erfolgt als entryRelationship-Element zu einer observation.-->
<ClinicalDocument>
  <observation classCode="OBS" moodCode="EVN">
    <templateId root="1.3.6.1.4.1.19376.1.3.1.3"/>    <id extension="P-13-1" root="2.16.840.1.113883.2.16.1.99.3.1"/>    <code code="14979-9" codeSystem="2.16.840.1.113883.6.1" displayName="aPTT"/>    <text>
      <reference value="#OBS-13-1"/>    </text>    <effectiveTime value="20121201073406"/>    <value unit="pg" value="57.0" xsi:type="PQ"/>    <entryRelationship typeCode="COMP">
      <act classCode="ACT" moodCode="EVN">
        <templateId root="1.2.40.0.34.11.4.3.2"/>        <templateId root="2.16.840.1.113883.10.20.1.40"/>        <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.2"/>        <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation Comment"/>        <text>
          <reference value="#footnote1"/>        </text>        <statusCode code="completed"/>      </act>    </entryRelationship>  </observation></ClinicalDocument>
Example
Kommentar zu einem Bereich/Speciality
<!--Die Angabe erfolgt als entryRelationship-Element im entry-Block einer Befundart (Speciality)-->
<ClinicalDocument>
  <entry typeCode="DRIV">
    <act classCode="ACT" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.3.1" extension="Lab.Report.Data.Processing.Entry"/>      <code code="26436-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Laboratory Studies"/>      <statusCode code="completed"/>       ...       <entryRelationship>
        <act classCode="ACT" moodCode="EVN">
          <templateId root="1.2.40.0.34.11.4.3.2"/>          <templateId root="2.16.840.1.113883.10.20.1.40"/>          <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.2"/>          <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation Comment"/>          <text>
            <reference value="#commonRemark1"/>          </text>          <statusCode code="completed"/>        </act>      </entryRelationship>    </act>  </entry></ClinicalDocument>
ItemDTCardConfDescriptionLabel
hl7:act
Annodotstion
@classCode
cs1 … 1FACT
@moodCode
cs1 … 1FEVN
hl7:templateId
II1 … 1RAnnodotstion
@root
uid1 … 1F1.2.40.0.34.11.4.3.2
hl7:templateId
II1 … 1RAnnodotstion
@root
uid1 … 1F2.16.840.1.113883.10.20.1.40
hl7:templateId
II1 … 1RAnnodotstion
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.2
hl7:code
CE1 … 1MAnnodotstion
@code
CONF1 … 1F48767-8
@codeSystem
1 … 1F2.16.840.1.113883.6.1
hl7:text
ED1 … 1Mde-DE Referenz auf den Text im narrativen Teil.Annodotstion
hl7:reference
1 … 1MAnnodotstion
@value
1 … 1R
hl7:statusCode
CS0 … 1Annodotstion
@code
CONF0 … 1Fcompleted