hl7:observation
|
|
|
|
|
(Problem… |
@classCode
|
cs |
1 … 1 |
F |
OBS |
@moodCode
|
cs |
1 … 1 |
F |
EVN |
@negationInd
|
bl |
0 … 1 |
|
|
hl7:templateId
|
|
1 … 1 |
M |
|
(Problem… |
@root
|
uid |
1 … 1 |
F |
1.2.276.0.76.10.4075 |
hl7:id
|
|
1 … * |
|
|
(Problem… |
hl7:code
|
|
1 … 1 |
M |
|
(Problem… |
| |
CONF |
|
hl7:statusCode
|
|
1 … 1 |
M |
|
(Problem… |
@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.
|
(Problem… |
hl7:low
|
|
1 … 1 |
M |
Das low Element gibt das Datum an, seit wann der Patient diese Problem hat |
(Problem… |
hl7:high
|
|
0 … 1 |
|
Das high Element gibt das Datum an, seit wann der Patient diese Problem nicht mehr
hat
|
(Problem… |
hl7:value
|
CD |
1 … 1 |
R |
|
(Problem… |
| |
CONF |
| muss aus der Konzeptdomäne "Problemcodes" gewählt werden |
|
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.
|
(Problem… |
hl7:translation
|
|
0 … * |
|
|
(Problem… |
@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 |
|
(Problem… |
| Eingefügt |
|
|
von 1.2.276.0.76.10.90025 Author (Body) (DYNAMIC)
|
@typeCode
|
|
0 … 1 |
F |
AUT |
@contextControlCode
|
|
0 … 1 |
F |
OP |
hl7:functionCode
|
CE |
0 … 1 |
|
|
(Problem… |
| |
CONF |
|
hl7:time
|
TS |
1 … 1 |
R |
|
(Problem… |
hl7:assignedAuthor
|
|
1 … 1 |
R |
|
(Problem… |
@classCode
|
|
0 … 1 |
F |
ASSIGNED |
hl7:id
|
II |
1 … * |
R |
|
(Problem… |
hl7:code
|
CE |
0 … 1 |
|
|
(Problem… |
@codeSystem
|
CONF |
1 … 1 |
F |
2.16.840.1.113883.5.111 (Role Code) |
hl7:addr
|
AD |
0 … * |
|
|
(Problem… |
hl7:telecom
|
TEL |
0 … * |
|
|
(Problem… |
hl7:assignedPerson
|
|
0 … 1 |
|
|
(Problem… |
| Eingefügt |
|
|
von 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC)
|
@classCode
|
|
0 … 1 |
F |
PSN |
@determinerCode
|
|
0 … 1 |
F |
INSTANCE |
hl7:name
|
PN |
1 … 1 |
|
|
(Problem… |
hl7:representedOrganization
|
|
0 … 1 |
|
|
(Problem… |
| Eingefügt |
|
|
von 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC)
|
@classCode
|
|
0 … 1 |
F |
ORG |
@determinerCode
|
|
0 … 1 |
F |
INSTANCE |
hl7:id
|
II |
0 … * |
|
|
(Problem… |
hl7:name
|
ON |
1 … 1 |
|
|
(Problem… |
hl7:telecom
|
TEL |
0 … * |
|
|
(Problem… |
hl7:addr
|
AD |
0 … 1 |
|
|
(Problem… |
hl7:entryRelationship
|
|
0 … 1 |
|
Alter des Patienten
Beinhaltet 1.2.276.0.76.10.4077 Alter Beobachtung (DYNAMIC)
|
(Problem… |
 |
wo [hl7:observation [hl7:templateId [@root='1.2.276.0.76.10.4077']]] |
|
|
@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)
|
(Problem… |
|
wo [hl7:observation [hl7:templateId [@root='1.2.276.0.76.10.4078']]] |
|
|
@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)
|
(Problem… |
|
wo [hl7:observation [hl7:templateId [@root='1.2.276.0.76.10.4076']]] |
|
|
@typeCode
|
cs |
1 … 1 |
F |
REFR |
hl7:entryRelationship
|
|
0 … * |
|
Manifestations-Beobachtung
Beinhaltet 1.2.276.0.76.10.4093 Manifestation Observation (DYNAMIC)
|
(Problem… |
|
wo [hl7:observation [hl7:templateId [@root='1.2.276.0.76.10.4093']]] |
|
|
@typeCode
|
cs |
1 … 1 |
F |
MFST |
hl7:entryRelationship
|
|
0 … * |
|
Ätiologie-Beobachtung
Beinhaltet 1.2.276.0.76.10.4094 Etiology Observation (DYNAMIC)
|
(Problem… |
|
wo [hl7:observation [hl7:templateId [@root='1.2.276.0.76.10.4094']]] |
|
|
@typeCode
|
cs |
1 … 1 |
F |
CAUS |
Template Problem Observation
Entwurf
Arztbrief (v2.01)