ref
hl7de-
Entwurf| Beschreibung |
 This template reflects a discrete observation about a patient's problem. Because it is a discrete observation, it will have a statusCode of "completed". The effectiveTime, also referred to as the “biologically relevant time” is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of heart attack that occurred five years ago, the effectiveTime is five years ago. The effectiveTime of the Problem Observation is the definitive indication of whether or not the underlying condition is resolved. If the problem is known to be resolved, then an effectiveTime/high would be present. If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK". |
| Benutzt von 3 Transactions und 9 Templates, Benutzt 6 Templates | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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ref
ad1bbr-
Adaptation: Template 2.16.840.1.113883.10.20.22.4.4 (2015‑08‑01)
ref
hl7de-
| Beispiel |
| <observation classCode="OBS" moodCode="EVN"> <!-- Problem Observation --> <templateId root="1.2.276.0.76.10.4075"/> <id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/> <code code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis"/> <!-- The statusCode reflects the status of the observation itself --> <statusCode code="completed"/> <effectiveTime> <!-- Das low Element gibt das Datum an, seit wann der Patient dieses Problem hat --> <low value="20130703"/> <!-- Das high Element gibt das Datum an, seit wann der Patient dieses Problem nicht mehr hat --> <high value="20130721"/> </effectiveTime> <!-- Im value Element wird das Problem angegeben. Dies kann ein ICD 10 Code oder ein anderer Code sein. --> <value xsi:type="CD" code="J11.1" codeSystem="1.2.276.0.76.5.430" displayName="Grippe mit sonstigen Manifestationen an den Atemwegen, Viren nicht nachgewiesen"/> <author typeCode="AUT"> <!-- optional: Autor des Problem --> </author></observation> |
| Item | DT | Kard | Konf | Beschreibung | Label | |
|---|---|---|---|---|---|---|
| hl7:observation | Prob tion | |||||
| @classCode | cs | 1 … 1 | F | OBS | ||
| @moodCode | cs | 1 … 1 | F | EVN | ||
| @negationInd | bl | 0 … 1 | ||||
| hl7:templateId | 1 … 1 | M | Probtion | |||
| @root | uid | 1 … 1 | F | 1.2.276.0.76.10.4075 | ||
| hl7:id | 1 … * | Probtion | ||||
| hl7:code | 1 … 1 | M | Probtion | |||
| CONF |
| |||||
| hl7:statusCode | 1 … 1 | M | Probtion | |||
| @code | CONF | 1 … 1 | F | completed | ||
| hl7:effectiveTime | 1 … 1 | M | If the problem is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'. Therefore, the existence of an high element within a problem does indicate that the problem has been resolved. | Probtion | ||
| hl7:low | 1 … 1 | M | Das low Element gibt das Datum an, seit wann der Patient diese Problem hat | Probtion | ||
| hl7:high | 0 … 1 | Das high Element gibt das Datum an, seit wann der Patient diese Problem nicht mehr hat | Probtion | |||
| hl7:value | CD | 1 … 1 | R | Probtion | ||
| CONF |
| |||||
| hl7:qualifier | 0 … * | This value MAY contain zero or more [0..*] qualifier (CONF:1198-31870). The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. For example, SNOMED CT allows constructing concepts as a combination of multiple codes. SNOMED CT defines a concept "pneumonia (disorder)" (233604007) an attribute "finding site" (363698007) and another concept "left lower lobe of lung (body structure)" (41224006). SNOMED CT allows one to combine these codes in a code phrase, as shown in the sample XML. | Probtion | |||
| hl7:translation | 0 … * | Probtion | ||||
| @code | 0 … 1 | MAY contain zero or one [0..1] @code (CodeSystem: ICD10CM urn:oid:2.16.840.1.113883.6.90 STATIC) (CONF:1198-16750). | ||||
| hl7:author | 0 … * | R | Probtion | |||
| Eingefügt | von 1.2.276.0.76.10.90025 Author (Body) (DYNAMIC) | |||||
| @typeCode | cs | 0 … 1 | F | AUT | ||
| @contextControlCode | cs | 0 … 1 | F | OP | ||
| hl7:functionCode | CE | 0 … 1 | AuthBody | |||
| CONF |
| |||||
| hl7:time | TS | 1 … 1 | R | AuthBody | ||
| hl7:assignedAuthor | 1 … 1 | R | AuthBody | |||
| @classCode | cs | 0 … 1 | F | ASSIGNED | ||
| hl7:id | II | 1 … * | R | AuthBody | ||
| hl7:code | CE | 0 … 1 | AuthBody | |||
| @codeSystem | CONF | 0 … 1 | F | 2.16.840.1.113883.5.111 | ||
| hl7:addr | AD | 0 … * | AuthBody | |||
| hl7:telecom | TEL | 0 … * | AuthBody | |||
| hl7:assignedPerson | 0 … 1 | AuthBody | ||||
| Eingefügt | von 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC) | |||||
| @classCode | cs | 0 … 1 | F | PSN | ||
| @determinerCode | cs | 0 … 1 | F | INSTANCE | ||
| hl7:name | PN | 1 … 1 | M | Persents | ||
| hl7:representedOrganization | 0 … 1 | AuthBody | ||||
| Eingefügt | von 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC) | |||||
| @classCode | cs | 0 … 1 | F | ORG | ||
| @determinerCode | cs | 0 … 1 | F | INSTANCE | ||
| hl7:id | II | 0 … * | Orgaents | |||
| hl7:name | ON | 1 … 1 | M | Orgaents | ||
| hl7:telecom | TEL | 0 … * | Orgaents | |||
| hl7:addr | AD | 0 … 1 | Orgaents | |||
| hl7:entryRelationship | 0 … 1 | Alter des Patienten Beinhaltet 1.2.276.0.76.10.4077 Alter Beobachtung (DYNAMIC) | Probtion | |||
| @typeCode | cs | 1 … 1 | F | SUBJ | ||
| @inversionInd | bl | 1 … 1 | F | true | ||
| hl7:entryRelationship | 0 … 1 | Prognose des Problems Beinhaltet 1.2.276.0.76.10.4078 Prognose Observation (DYNAMIC) | Probtion | |||
| @typeCode | cs | 1 … 1 | F | REFR | ||
| hl7:entryRelationship | 0 … * | Schweregrad des Problems laut Einschätzung des Gesundheitsdienstleisters Beinhaltet 1.2.276.0.76.10.4076 Priorität Präferenz (DYNAMIC) | Probtion | |||
| @typeCode | cs | 1 … 1 | F | REFR | ||
| hl7:entryRelationship | 0 … * | Manifestations-Beobachtung Beinhaltet 1.2.276.0.76.10.4093 Manifestation Observation (DYNAMIC) | Probtion | |||
| @typeCode | cs | 1 … 1 | F | MFST | ||
| hl7:entryRelationship | 0 … * | Ätiologie-Beobachtung Beinhaltet 1.2.276.0.76.10.4094 Etiology Observation (DYNAMIC) | Probtion | |||
| @typeCode | cs | 1 … 1 | F | CAUS | ||