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Template Indication 2013‑01‑31

Id	2.16.840.1.113883.10.20.22.4.19 ref ccda-	Gültigkeit ab	2013‑01‑31
Status	Entwurf	Versions-Label	1.1
Name	Indication	Bezeichnung	Indication
Beschreibung The Indication Observation documents the rationale for an activity. It can do this with the id element to reference a problem recorded elsewhere in the document or with a code and value to record the problem type and problem within the Indication. For example, the indication for a prescription of a painkiller might be a headache that is documented in the Problems Section.
Kontext	Elternknoten des Template-Element mit Id 2.16.840.1.113883.10.20.22.4.19
Klassifikation	CDA Entry Level Template
Offen/Geschlossen	Offen (auch andere als die definierten Elemente sind erlaubt)
Benutzt von / Benutzt	Benutzt von 7 Transactions und 39 Templates, Benutzt 0 Templates Benutzt von als Name Version 2.16.840.1.113883.3.1937.99.3.4.4 Transaktion Progress Note (Release 1.1) 2013‑01‑31 2.16.840.1.113883.3.1937.99.3.4.3 Transaktion Discharge Summary (Release 1.1) 2013‑01‑31 2.16.840.1.113883.3.1937.99.3.4.5 Transaktion Procedure Note (US Realm – Release 1) 2013‑01‑31 2.16.840.1.113883.3.1937.99.3.4.2 Transaktion Consultation Notes (Release 1.1) 2013‑01‑31 2.16.840.1.113883.3.1937.99.3.4.1 Transaktion Continuity of Care Document (CCD) (Release 1.1) 2013‑01‑31 2.16.840.1.113883.3.1937.99.3.4.6 Transaktion Operative Note (Release 1.1) 2013‑01‑31 2.16.840.1.113883.3.1937.99.3.4.7 Transaktion History and Physical (H and P) (Release 1.1) 2013‑01‑31 2.16.840.1.113883.3.1937.99.61.26.10.52 Containment Procedure Activity Procedure (1.1) 2019‑03‑06 11:55:46 2.16.840.1.113883.3.1937.99.61.41.10.4 Discharge Summary (1.1) 2018‑02‑19 15:30:38 2.16.840.1.113883.3.1937.777.24.10.14 Containment Medication Activity (1.1) 2019‑01‑16 10:56:33 2.16.840.1.113883.10.20.22.1.2 Continuity of Care Document (CCD) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.1.3 History and Physical (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.1.4 Consultation Note (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.1.6 Procedure Note (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.1.7 Operative Note (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.1.8 Discharge Summary (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.1.9 Progress Note (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.1 Medications Section (entries optional) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.1.1 Medications Section (entries required) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.2 Encounters Section (entries optional) (1.1) 2016‑10‑09 02:21:23 2.16.840.1.113883.10.20.22.2.2.1 Immunizations Section (entries required) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.6 Allergies Section (entries optional) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.6.1 Allergies Section (entries required) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.7.1 Procedures Section (entries required) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.11 Hospital Discharge Medications Section (entries optional) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.11.1 Hospital Discharge Medications Section (entries required) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.22 Encounters Section (entries optional) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.22.1 Encounters Section (entries required) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.25 Anesthesia Section (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.29 Containment Procedure Indications Section (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.38 Medications Administered Section (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.44 Hospital Admission Medications Section (entries optional) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.4.7 Allergy - Intolerance Observation (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.4.9 Reaction Observation (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.4.12 Containment Procedure Activity Act (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.4.13 Containment Procedure Activity Observation (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.4.14 Containment Procedure Activity Procedure (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.4.16 Containment Medication Activity (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.4.30 Allergy Problem Act (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.4.35 Discharge Medication (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.4.36 Admission Medication (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.4.49 Containment Encounter Activities (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.4.52 Containment Immunization Activity (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.24.3.90 Substance or Device Allergy - Intolerance Observation (1.1) 2013‑01‑31
Alles ausklappenAlles einklappen Item DT Kard Konf Beschreibung Label cda:observation Indition @classCode cs 1 … 1 F OBS conf‑7480 @moodCode cs 1 … 1 F EVN conf‑7481 cda:templateId II 1 … 1 M SHALL contain exactly one [1..1] templateId (CONF:7482) such that it conf‑7482 @root uid 1 … 1 F 2.16.840.1.113883.10.20.22.4.19 conf0502 cda:id II 1 … * R SHALL contain exactly one [1..1] id (CONF:7483). Set the observation/id equal to an ID on the problem list to signify that problem as an indication. conf‑7483 cda:code CD (extensible) 1 … 1 R SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Problem Type 2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2012-06-01 (CONF:16886). conf6886   CONF Der Wert von @code sollte gewählt werden aus dem Value Set 2.16.840.1.113883.3.88.12.3221.7.2 Problem Type (DYNAMIC) cda:statusCode CS 1 … 1 M SHALL contain exactly one [1..1] statusCode (CONF:7487). conf‑7487 @code CONF 1 … 1 F completed cda:effectiveTime IVL_TS 0 … 1 R SHOULD contain zero or one [0..1] effectiveTime (CONF:7488). conf‑7488 cda:value CD (extensible) 0 … 1 R SHOULD contain zero or one [0..1] value with @xsi:type="CD" (CONF:7489). If the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the code is something other than SNOMED, @nullFlavor SHOULD be “OTH” and the other code SHOULD be placed in the translation element conf‑7489 @nullFlavor cs 0 … 1   conf5990 @code 0 … 1   conf5985