| Item | DT | Kard | Konf | Beschreibung | Label |
|---|
cda:observation
| | | | | Goal tion |
@classCode
| cs | 1 … 1 | F | OBS | CONF0418 |
| |  SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1098-30418). |
@moodCode
| cs | 1 … 1 | F | GOL | CONF0419 |
| | SHALL contain exactly one [1..1] @moodCode="GOL" Goal (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1098-30419). |
cda:templateId
| II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1098-8583) such that it | CONF8583 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.4.121 | CONF0512 |
| | SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.121" (CONF:1098-10512). |
cda:id
| II | 1 … * | | SHALL contain at least one [1..*] id (CONF:1098-32332). | CONF2332 |
cda:code
| CD (extensible) | 1 … 1 | | SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:1098-30784). | CONF0784 |
@codeSystem
| CONF | 0 … 1 | F | 2.16.840.1.113883.6.1 |
cda:statusCode
| CS | 1 … 1 | M | SHALL contain exactly one [1..1] statusCode (CONF:1098-32333). | CONF2333 |
@code
| CONF | 1 … 1 | F | active |
cda:effectiveTime
| IVL_TS | 0 … 1 | R | SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-32335). | CONF2335 |
cda:value
| | 0 … 1 | | MAY contain zero or one [0..1] value (CONF:1098-32743). | CONF2743 |
cda:author
| | 0 … * | | SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-30995).
If the author is set to the recordTarget (patient), this is a patient goal. If the author is set to a provider, this is a provider goal. If both patient and provider are set as authors, this is a negotiated goal.
Beinhaltet 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13) | CONF0995 |
cda:entryRelationship
| | 0 … * | | The following entryRelationship represents the relationship between a Goal Observation and a Health Concern Act (Goal Observation REFERS TO Health Concern Act). As Health Concern Act is already defined in Health Concerns Section, rather than clone the whole Health Concern Act template, an Entry Reference may be used in entryRelationship to refer the template.
Beinhaltet 2.16.840.1.113883.10.20.22.4.122 Entry Reference (2015‑08‑13) | CONF0701 |
| wo [@typeCode='REFR'] | |
@typeCode
| cs | 1 … 1 | F | REFR | CONF0702 |
| | SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-30702). |
cda:entryRelationship
| | 0 … * | | The following entryRelationship represents a planned component of the goal such as Planned Encounter (V2), Planned Observation (V2), Planned Procedure (V2), Planned Medication Activity (V2), Planned Supply (V2), Planned Act (V2) or Planned Immunization Activity. Because these entries are already described in the Interventions Section of the CDA document instance, rather than repeating the full content of the entries, the Entry Reference template may be used to reference the entries.
Beinhaltet 2.16.840.1.113883.10.20.22.4.122 Entry Reference (2015‑08‑13) | CONF0704 |
| wo [@typeCode='COMP'] | |
@typeCode
| cs | 1 … 1 | F | COMP | CONF0705 |
| | SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-30705). |
cda:entryRelationship
| | 0 … 1 | R | The following entryRelationship represents the priority that the patient or a provider puts on the goal.
Beinhaltet 2.16.840.1.113883.10.20.22.4.143 Priority Preference (2015‑08‑13) | CONF0785 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF0786 |
| | SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-30786). |
cda:entryRelationship
| | 0 … * | | The following entryRelationship represents the relationship between two Goal Observations where the target is a component of the source (Goal Observation HAS COMPONENT Goal Observation). The component goal (target) is a Milestone.
Beinhaltet 2.16.840.1.113883.10.20.22.4.121 Goal Observation (2015‑08‑13) | CONF1448 |
@typeCode
| cs | 1 … 1 | F | COMP | CONF1449 |
| | SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-31449). |
cda:entryRelationship
| | 0 … * | | Where a Goal Observation needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry.
Beinhaltet 2.16.840.1.113883.10.20.22.4.122 Entry Reference (2015‑08‑13) | CONF1559 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF1560 |
| | SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-31560). |
cda:reference
| | 0 … * | | Where it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument.
Beinhaltet 2.16.840.1.113883.10.20.22.4.115 External Document Reference (2014‑06‑09) | CONF2754 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF2755 |
| | The reference, if present, SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32755). |
Entwurf
