Unter Revision vor der Publikation| Beschreibung |
 CONF-128: A problem observation or result observation in the functional status section SHALL contain exactly one observation / code. ... 3.5.2.1.2 Problem observationCONF-154: A problem observation (templateId 2.16.840.1.113883.10.20.1.28) SHALL be represented with Observation. CONF-155: The value for “Observation / @moodCode” in a problem observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC. CONF-156: A problem observation SHALL include exactly one Observation / statusCode. CONF-157: The value for “Observation / statusCode” in a problem observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC. CONF-158: A problem observation SHOULD contain exactly one Observation / effectiveTime, to indicate the biological timing of condition (e.g. the time the condition started, the onset of the illness or symptom, the duration of a condition). CONF-159: The value for “Observation / code” in a problem observation MAY be selected from ValueSet 2.16.840.1.113883.1.11.20.14 ProblemTypeCode STATIC 20061017. CONF-160: The value for “Observation / entryRelationship / @typeCode” in a problem observation MAY be “SUBJ” “Subject” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC to reference an age observation (templateId 2.16.840.1.113883.10.20.1.38). CONF-161: A problem observation SHALL contain one or more sources of information, as defined in section 5.2 Source. |
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| Item | DT | Kard | Konf | Beschreibung | Label | |
|---|---|---|---|---|---|---|
| hl7:observation | Prob tion | |||||
| @classCode | cs | 0 … 1 | ||||
| CONF |
| |||||
| @moodCode | cs | 1 … 1 | F | EVN | CONF‑155 | |
| @negationInd | bl | 0 … 1 | ||||
| Schematron assert | role |  warning | ||||
| test | hl7:informant or hl7:reference[@typeCode='XCRPT'] or hl7:entryRelationship[@typeCode='REFR']/hl7:observation[@classCode='OBS'][@moodCode='EVN'][hl7:statusCode/@code='completed'][hl7:code[@code='48766-0'][@codeSystem='2.16.840.1.113883.6.1'][@displayName='Information source']][hl7:value] | |||||
| Meldung | CONF-161: A problem observation SHALL contain one or more sources of information, as defined in section 5.2 Source. | |||||
| Schematron assert | role |  error | ||||
| test | (not(hl7:entryRelationship[hl7:observation/hl7:templateId/@root='2.16.840.1.113883.10.20.1.44']) or ancestor::hl7:section[hl7:templateId/@root='2.16.840.1.113883.10.20.1.5']) and (not(ancestor::hl7:section[hl7:templateId/@root='2.16.840.1.113883.10.20.1.5']) or hl7:entryRelationship[hl7:observation/hl7:templateId/@root='2.16.840.1.113883.10.20.1.44']) | |||||
| Meldung | CONF-136: A problem observation in the functional status section SHALL contain exactly one status of functional status observation. | |||||
| hl7:templateId | II | 1 … 1 | Probtion | |||
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.1.28 | ||
| hl7:id | II | 0 … * | Probtion | |||
| hl7:code | CD | 1 … 1 | R | CONF-129: The value for “Observation / code” in a problem observation or result observation in the functional status section MAY be selected from ValueSet 2.16.840.1.113883.1.11.20.6 FunctionalStatusTypeCode STATIC 20061017. | CONF‑128 | |
| hl7:derivationExpr | ST | 0 … 1 | Probtion | |||
| hl7:text | ED | 0 … 1 | Probtion | |||
| hl7:statusCode | CS | 1 … 1 | M | CONF‑156 / CONF‑157 | ||
| @code | CONF | 1 … 1 | F | completed | ||
| hl7:effectiveTime | IVL_TS | 1 … 1 | R | Probtion | ||
| hl7:priorityCode | CE | 0 … 1 | Probtion | |||
| CONF |
| |||||
| hl7:repeatNumber | IVL_INT | 0 … 1 | Probtion | |||
| hl7:languageCode | CS | 0 … 1 | Probtion | |||
| CONF |
| |||||
| hl7:value | 0 … * | Probtion | ||||
| hl7:interpretationCode | CE | 0 … * | Probtion | |||
| CONF |
| |||||
| hl7:methodCode | CE | 0 … * | Probtion | |||
| CONF |
| |||||
| hl7:targetSiteCode | CD | 0 … * | Probtion | |||
| CONF |
| |||||
| hl7:subject | 0 … 1 | Beinhaltet 2.16.840.1.113883.3.1937.777.4.10.3 CCD Subject (Body) (DYNAMIC) | Probtion | |||
| hl7:informant | 0 … * | Beinhaltet 2.16.840.1.113883.3.1937.777.4.10.20 CCD Informant (Body) (DYNAMIC) | CONF‑161 | |||
| hl7:participant | 0 … 1 | Beinhaltet 2.16.840.1.113883.10.20.1.48 Patient awareness (DYNAMIC) | CONF‑178 / CONF‑179 / CONF‑180 | |||
| hl7:entryRelationship | 0 … 1 | Beinhaltet 2.16.840.1.113883.10.20.1.44 Status of functional status observation (DYNAMIC) | CONF‑136 | |||
| @typeCode | cs | 1 … 1 | F | REFR | CONF‑509 | |
| @contextConductionInd | bl | 0 … 1 | ||||
| @inversionInd | bl | 0 … 1 | ||||
| @negationInd | bl | 0 … 1 | ||||
| hl7:sequenceNumber | INT | 0 … 1 | CONF‑136 | |||
| hl7:seperatableInd | BL | 0 … 1 | CONF‑136 | |||
| hl7:entryRelationship | 0 … 1 | Beinhaltet 2.16.840.1.113883.10.20.1.38 Age observation (DYNAMIC) | CONF‑160 | |||
| @typeCode | cs | 1 … 1 | F | SUBJ | CONF‑160 | |
| @contextConductionInd | bl | 0 … 1 | ||||
| @inversionInd | bl | 0 … 1 | ||||
| @negationInd | bl | 0 … 1 | ||||
| hl7:sequenceNumber | INT | 0 … 1 | CONF‑160 | |||
| hl7:seperatableInd | BL | 0 … 1 | CONF‑160 | |||
| hl7:entryRelationship | 0 … 1 | Beinhaltet 2.16.840.1.113883.10.20.1.50 Problem status observation (DYNAMIC) | CONF‑162 | |||
| @typeCode | cs | 1 … 1 | F | REFR | CONF‑509 | |
| @contextConductionInd | bl | 0 … 1 | ||||
| @inversionInd | bl | 0 … 1 | ||||
| @negationInd | bl | 0 … 1 | ||||
| hl7:sequenceNumber | INT | 0 … 1 | CONF‑162 | |||
| hl7:seperatableInd | BL | 0 … 1 | CONF‑162 | |||
| hl7:entryRelationship | 0 … 1 | Beinhaltet 2.16.840.1.113883.10.20.1.51 Problem healthstatus observation (DYNAMIC) | CONF‑165 | |||
| @typeCode | cs | 1 … 1 | F | REFR | CONF‑509 | |
| @contextConductionInd | bl | 0 … 1 | ||||
| @inversionInd | bl | 0 … 1 | ||||
| @negationInd | bl | 0 … 1 | ||||
| hl7:sequenceNumber | INT | 0 … 1 | CONF‑165 | |||
| hl7:seperatableInd | BL | 0 … 1 | CONF‑165 | |||
| hl7:entryRelationship | 0 … * | Beinhaltet 2.16.840.1.113883.10.20.1.40 Comment (DYNAMIC) | CONF‑502 | |||
| @typeCode | cs | 1 … 1 | R | |||
| CONF |
| |||||
| @contextConductionInd | bl | 0 … 1 | ||||
| @inversionInd | bl | 0 … 1 | ||||
| @negationInd | bl | 0 … 1 | ||||
| hl7:sequenceNumber | INT | 0 … 1 | CONF‑502 | |||
| hl7:seperatableInd | BL | 0 … 1 | CONF‑502 | |||
| hl7:entryRelationship | 0 … * | CONF‑161 | ||||
| @typeCode | cs | 1 … 1 | F | REFR | CONF‑524 | |
| @contextConductionInd | bl | 0 … 1 | ||||
| @inversionInd | bl | 0 … 1 | ||||
| @negationInd | bl | 0 … 1 | ||||
| hl7:sequenceNumber | INT | 0 … 1 | CONF‑161 | |||
| hl7:seperatableInd | BL | 0 … 1 | CONF‑161 | |||
| hl7:observation | 1 … 1 | CONF‑523 / CONF‑525 | ||||
| @classCode | cs | 0 … 1 | CONF‑526 | |||
| CONF |
| |||||
| @moodCode | cs | 1 … 1 | F | EVN | CONF‑527 | |
| hl7:code | CD | 1 … 1 | M | CONF‑530 / CONF‑531 | ||
| @code | CONF | 1 … 1 | F | 48766-0 | ||
| @codeSystem | 1 … 1 | F | 2.16.840.1.113883.6.1 | |||
| @displayName | 1 … 1 | F | Information source | |||
| hl7:statusCode | CS | 1 … 1 | M | CONF‑528 / CONF‑529 | ||
| @code | CONF | 1 … 1 | F | completed | ||
| hl7:value | 1 … 1 | M | CONF‑532 / CONF‑533 | |||
| hl7:reference | 0 … * | CONF‑161 | ||||
| wo [@typeCode='XCRPT'] | ||||||
| hl7:referenceRange | 0 … * | Probtion | ||||
| @typeCode | cs | 0 … 1 | F | REFV | ||
| hl7:observationRange | 1 … 1 | Probtion | ||||
| @classCode | cs | 0 … 1 | ||||
| CONF |
| |||||
| @moodCode | cs | 0 … 1 | ||||
| CONF |
| |||||
| hl7:code | CD | 0 … 1 | Probtion | |||
| CONF |
| |||||
| hl7:text | ED | 0 … 1 | Probtion | |||
| hl7:value | 0 … 1 | Probtion | ||||
| hl7:interpretationCode | CE | 0 … 1 | Probtion | |||
| CONF |
| |||||