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Template Findings 2017‑09‑08 10:23:39

Id2.16.756.5.30.1.1.10.3.14Effective Date2017‑09‑08 10:23:39
Statusdraft DraftVersion Label2017
NameFindingsSectionDisplay NameFindings
DescriptionFindings Section
ContextParent nodes of template element with id 2.16.756.5.30.1.1.10.3.14
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 1 concept
IdNameData Set
cdachresp-dataelement-17draft Befund draft  1
Used by / Uses
Used by 1 transaction and 1 template, Uses 4 templates
Used by as NameVersion
2.16.756.5.30.1.127.77.5.4.12Transactiondraft Emergency Service Protocol (2017)2017‑01‑25 22:10:05
2.16.756.5.30.1.1.10.1.2Containmentpending EmergencyMedicalServiceProtocol (2017)2017‑06‑13 17:19:29
Uses as NameVersion
1.2.276.0.76.10.4034Containmentactive Glasgow Coma ScaleDYNAMIC
2.16.756.5.30.1.1.10.4.64Containmentpending Level of Responsiveness (AVPU) (2017)DYNAMIC
2.16.756.5.30.1.1.10.4.80Containmentpending Observation Cardiac Arrest (2017)DYNAMIC
2.16.756.5.30.1.1.10.4.82Containmentpending Observation Airways (2017)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
Example
Example
<section>
  <templateId root="2.16.756.5.30.1.1.10.3.14"/>  <code code="1100006" codeSystem="2.16.756.5.30.1.143.5.1" displayName="Befund" codeSystemName="IVR Codesystem RESP"/>  <title>Befund</title>  <text>
    <paragraph>
      
Blutdruck 120/80 mmHg gemessen am rechten Arm
      <br/>      
Schmerz 5
      <br/>    </paragraph>    <table>
      <tbody>
        <tr>
          <th>GCS</th>        </tr>        <tr>
          <td ID="gcs1">Total 15 (Augenöffnung spontan 4/ verbale Antwort
orientiert 5/ morot. Reaktion befolgt Antweisungen 6) um 12:25
</td>        </tr>      </tbody>    </table>  </text>  <entry>
    <!-- cdachresp-dataelement-108 GCS -->
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="1.2.276.0.76.10.4034"/>      <id root="1.2.276.0.76.4.17.9814184919" extension="98C1EB7E-DC2D-4D1F-806A-2AD65EBA0351"/>      <code code="9269-2" codeSystem="2.16.840.1.113883.6.1" displayName="Glasgow coma score total"/>      <text>
        <reference value="#gcs1"/>      </text>      <statusCode code="completed"/>      <effectiveTime value="20161210112500.0000+0100"/>      <!-- cdachresp-dataelement-109 -->
      <value xsi:type="PQ" value="15" unit="{score}"/>      <entryRelationship typeCode="COMP" contextConductionInd="true">
        <observation classCode="OBS" moodCode="EVN">
          <code code="9267-6" codeSystem="2.16.840.1.113883.6.1" displayName="Glasgow coma score eye opening"/>          <statusCode code="completed"/>          <!-- cdachresp-dataelement-110 -->
          <value xsi:type="PQ" value="4" unit="{score}"/>        </observation>      </entryRelationship>      <entryRelationship typeCode="COMP" contextConductionInd="true">
        <observation classCode="OBS" moodCode="EVN">
          <code code="9270-0" codeSystem="2.16.840.1.113883.6.1" displayName="Glasgow coma score verbal"/>          <statusCode code="completed"/>          <!-- cdachresp-dataelement-111 -->
          <value xsi:type="PQ" value="5" unit="{score}"/>        </observation>      </entryRelationship>      <entryRelationship typeCode="COMP" contextConductionInd="true">
        <observation classCode="OBS" moodCode="EVN">
          <code code="9268-4" codeSystem="2.16.840.1.113883.6.1" displayName="Glasgow coma score motor"/>          <statusCode code="completed"/>          <!-- cdachresp-dataelement-112 -->
          <value xsi:type="PQ" value="6" unit="{score}"/>        </observation>      </entryRelationship>    </observation>  </entry></section>
ItemDTCardConfDescriptionLabel
hl7:section
Finddotstion
 
target
cdachresp-dataelement-17draft Befund draft  1
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cs0 … 1FDOCSECT
@moodCode
cs0 … 1FEVN
hl7:templateId
II1 … 1MFinddotstion
@root
uid1 … 1F2.16.756.5.30.1.1.10.3.14
hl7:code
CE1 … 1MFinddotstion
@code
CONF1 … 1F1100006
@codeSystem
1 … 1F2.16.756.5.30.1.143.5.1
@codeSystemName
1 … 1FIVR Codesystem RESP
@displayName
1 … 1FBefund
hl7:title
ST1 … 1M Fixed human readable title of this section.
  • [ge]: 'Befund'
  • [fr]: 'TODO'
  • [it]: 'TODO'
  • [en]: 'TODO'
The German title must read 'Befund'		Finddotstion
hl7:text
SD.TEXT1 … 1MHuman readable text of this section.Finddotstion
hl7:entry
0 … 1Contains 1.2.276.0.76.10.4034 Glasgow Coma Scale (DYNAMIC)Finddotstion
hl7:entry
0 … 1Contains 2.16.756.5.30.1.1.10.4.64 Level of Responsiveness (AVPU) (DYNAMIC)Finddotstion
hl7:entry
0 … 1Contains 2.16.756.5.30.1.1.10.4.82 Observation Airways (DYNAMIC)Finddotstion
hl7:entry
0 … 1Contains 2.16.756.5.30.1.1.10.4.80 Observation Cardiac Arrest (DYNAMIC)Finddotstion