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Template Problem Status Observation Entry 2017‑07‑13 20:51:44

Id1.2.40.0.34.11.13.3.13Gültigkeit ab2017‑07‑13 20:51:44
Statusdraft EntwurfVersions-Label0.1
NameProblemStatusObservationEntryBezeichnungProblem Status Observation Entry
Beschreibung
Klinischer Status des Problems
KontextElternknoten des Template-Element mit Id 1.2.40.0.34.11.13.3.13
KlassifikationCDA Entry Level Template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
BeziehungAdaptation: Template 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 (2013‑12‑20)
Beispiel
Beispiel
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.20.1.57"/>  <templateId root="2.16.840.1.113883.10.20.1.50"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.1.1"/>  <code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <text>
    <reference value="#cstatus-2"/>  </text>  <statusCode code="completed"/>  <value xsi:type="CE" code=" " codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/></observation>
ItemDTKardKonfBeschreibungLabel
hl7:observation
Probdotsntry
@classCode
cs0 … 1FOBS
@moodCode
cs0 … 1FEVN
hl7:templateId
II1 … 1MProbdotsntry
@root
uid1 … 1F1.2.40.0.34.11.13.3.13
hl7:templateId
II1 … 1RProbdotsntry
@root
uid1 … 1F2.16.840.1.113883.10.20.1.57
hl7:templateId
II1 … 1RProbdotsntry
@root
uid1 … 1F2.16.840.1.113883.10.20.1.50
hl7:templateId
II1 … 1RProbdotsntry
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.1.1
hl7:code
CD1 … 1Ren-US

This observation is of clinical status, as indicated by the <code> element. This element must be present.

Probdotsntry
@code
CONF0 … 1F33999-4
@codeSystem
0 … 1F2.16.840.1.113883.6.1
@codeSystemName
0 … 1FLOINC
@displayName
0 … 1FStatus
hl7:text
ED1 … 1Men-US

The <text> element is required and points to the text describing the problem being recorded; including any dates, comments, et cetera. The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.

Probdotsntry
hl7:reference
TEL1 … 1MProbdotsntry
@value
1 … 1Ren-US Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
hl7:statusCode
CS1 … 1Men-US

The code attribute of <statusCode> for all clinical status observations shall be completed. While the <statusCode> element is required in all acts to record the status of the act, the only sensible value of this element in this context is completed.

Probdotsntry
@code
CONF1 … 1Fcompleted
hl7:value
CE.EPSOS1 … 1Ren-US The <value> element contains the clinical status. It is always represented using the CE datatype (xsi:type='CE'). It shall contain a code from the following set of values from SNOMED CT.Probdotsntry
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 1.3.6.1.4.1.12559.11.10.1.3.1.42.15 (DYNAMIC)