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Template FAST Befunde 2017‑02‑21

Id1.2.276.0.76.10.4105Effective 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)
Associated with
Associated with 7 concepts
IdNameData Set
aktin-dataelement2016(1)-769draft de-DE Präklinik: FAST Befunde draft de-DE Traumamodul-Datensatz v2015.1-t
aktin-dataelement2016(1)-491draft de-DE Präklinik: FAST draft de-DE Traumamodul-Datensatz v2015.1-t
aktin-dataelement2016(1)-14draft de-DE FAST draft de-DE Traumamodul-Datensatz v2015.1-t
aktin-dataelement2016(1)-615draft de-DE FAST draft de-DE Traumamodul-Datensatz v2015.1-t
aktin-dataelement2016(1)-616draft de-DE FAST o.p.B. draft de-DE Traumamodul-Datensatz v2015.1-t
aktin-dataelement2016(1)-617draft de-DE Zeitpunkt FAST draft de-DE Traumamodul-Datensatz v2015.1-t
aktin-dataelement2016(1)-618draft de-DE FAST Befund draft de-DE Traumamodul-Datensatz v2015.1-t
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
 
target
aktin-dataelement2016(1)-769draft de-DE Präklinik: FAST Befunde draft de-DE Traumamodul-Datensatz v2015.1-t
aktin-dataelement2016(1)-491draft de-DE Präklinik: FAST draft de-DE Traumamodul-Datensatz v2015.1-t
aktin-dataelement2016(1)-14draft de-DE FAST draft de-DE Traumamodul-Datensatz v2015.1-t
@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
 
target
aktin-dataelement2016(1)-618draft de-DE FAST Befund draft de-DE Traumamodul-Datensatz v2015.1-t
hl7:reference
URL1 … 1FASTdotsings
hl7:statusCode
CS1 … 1MFASTdotsings
@code
CONF1 … 1Fcompleted
hl7:effectiveTime
TS0 … 1de-DE Zeitpunkt der UntersuchungFASTdotsings
 
target
aktin-dataelement2016(1)-617draft de-DE Zeitpunkt FAST draft de-DE Traumamodul-Datensatz v2015.1-t
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]
 
target
aktin-dataelement2016(1)-615draft de-DE FAST draft de-DE Traumamodul-Datensatz v2015.1-t
@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]
 
target
aktin-dataelement2016(1)-616draft de-DE FAST o.p.B. draft de-DE Traumamodul-Datensatz v2015.1-t
 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