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draft Template  Allergien und Intoleranzen

Id 1.2.40.0.34.11.13.2.1 Gültigkeit 2016‑11‑10 20:39:16
Status draft Entwurf Versions-Label 0.1
Name AllergienUnvertraeglichkeiten Anzeigename Allergien und Intoleranzen
Beschreibung
Diese Sektion enthält relevante Allergien oder Intoleranzen des Patienten.
Angegeben werden vorzugsweise die auslösende Substanz, die Art der Reaktion (Hautausschlag, Anaphylaxie, Erbrechen, ...), die Kritikalität sowie eine Angabe, wie gesichert die Information ist. Grundsätzlich sollen nur relevante Allergien und Intoleranzen angeführt werden. 
Wenn keine relevanten Allergien oder Intoleranzen vorliegen oder keine Information verfügbar ist, soll das klar erkennbar dokumentiert werden. Nicht relevante Intoleranzen oder Allergien sollen nicht angegeben werden. 
Alle enthaltenen Informationen MÜSSEN auch maschinenlesbar verfügbar sein, wenn keine Informationen vorliegen, ist das ebenfalls mit einem Code auszudrücken.
Kontext Elternknoten des Template-Element mit Id 1.2.40.0.34.11.13.2.1
Klassifikation CDA Section level template
Offen/Geschlossen Offen (auch andere als die definierten Elemente sind erlaubt)
Benutzt von / Benutzt
Benutzt von 0 Transactions und 0 Templates, Benutzt 4 Templates
Benutzt als Name Version
1.2.40.0.34.11.13.3.16 Containment draft Author (Body) PS DYNAMIC
1.2.40.0.34.11.13.3.20 Containment draft Informant (Body) PS (0.1) DYNAMIC
1.2.40.0.34.11.13.3.1 Containment draft Allergien und Intoleranzen Entry (0.1) DYNAMIC
1.2.40.0.34.11.13.2.18 Containment draft Übersetzung (0.1) DYNAMIC
Beispiel
Strukturbeispiel
<section>
  <templateId root="1.2.40.0.34.11.13.2.1"/>  <code code="48765-2" codeSystem="2.16.840.1.113883.6.1"/>  <title>Allergien und Intoleranzen</title>  <text/>  <author>
    <!-- template 1.2.40.0.34.11.13.3.16 'Author (Body) PS' (dynamic) -->
  </author>  <informant>
    <!-- template 1.2.40.0.34.11.13.3.20 'Informant (Body) PS' (dynamic) -->
  </informant>  <entry typeCode="DRIV">
    <!-- template 1.2.40.0.34.11.13.3.1 'Allergien und Unverträglichkeiten Entry' (dynamic) -->
  </entry></section>
Beispiel
Vollständig
<section>
  <templateId root="1.2.40.0.34.11.13.2.1"/>  <code code="48765-2" codeSystem="2.16.840.1.113883.6.1"/>  <title>Allergien und Intoleranzen</title>  <text>
    <table>
      <tr>
        <th>Auslösende Substanz</th>        <th>Überempfindlichkeit</th>        <th/>      </tr>      <tr>
        <td ID="alg1">Metamizol</td>        <td ID="typ1">Allergie</td>        <td>
          <ul>
            <li>Bekannt seit 2013-04</li>            <li>
              <content ID="react1">Reaktion: Larynxödem</content>              (               <content ID="sev1">Schweregrad: mittel</content>              )            </li>            <li ID="crit1">Lebensbedrohlich</li>            <li ID="cert1">Diagnosesicherheit: bestätigt</li>            <li ID="status1">klinischer Status: bestehend</li>            <li ID="auth1">Author: Dr.Isabella Stern</li>            <li ID="doc1">Quelle: Ärztlicher Entlassungsbrief 2015-03-18 Amadeus Spital Salzburg</li>          </ul>        </td>      </tr>      <tr>
        <td ID="alg2">Erdnuss (Arachis hypogaea)</td>        <td ID="typ2">Intoleranz</td>        <td>
          <ul>
            <li>Bekannt seit 2002-12</li>            <li>
              <content ID="react2">Reaktion: Durchfall</content>              (               <content ID="sev2">Schweregrad: mittel</content>              )            </li>            <li>
              <content ID="react3">Reaktion: Urtikaria</content>              (               <content ID="sev3">Schweregrad: schwer</content>              )            </li>            <li ID="crit2">Nicht Lebensbedrohlich</li>            <li ID="cert2">Diagnosesicherheit: bestätigt</li>            <li ID="status2">klinischer Status: bestehend</li>            <li>Informant: Eigenangabe des Patienten</li>          </ul>        </td>      </tr>      <tr>
        <td ID="alg3">Schokolade</td>        <td ID="typ3">Überempfindlichkeit</td>        <td>(keine weiteren Details)</td>      </tr>    </table>  </text>  <entry typeCode="DRIV">
    <!-- template 1.2.40.0.34.11.13.3.1 'Allergien und Unverträglichkeiten Entry' (dynamic) -->
    <act>
      <templateId root="1.2.40.0.34.11.13.3.1"/>      <id root="1.2.3.999" extension="--example only--"/>      <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>      <statusCode code="active"/>      <effectiveTime>
        <low value="20130400"/>      </effectiveTime>      <author typeCode="AUT" contextControlCode="OP">
        <!-- template 1.2.40.0.34.11.13.3.16 'Author (Body) PS' (2017-08-05T19:04:45) -->
        <time value="UNK"/>        <assignedAuthor classCode="ASSIGNED">
          <id root="1.2.3.999" extension="--example only--"/>          <code code="107" displayName="Fachärztin/Facharzt für Chirurgie" codeSystem="1.2.40.0.34.5.160" codeSystemName="ELGA_Fachaerzte"/>          <assignedPerson classCode="PSN" determinerCode="INSTANCE">
            <name>
              <prefix qualifier="AC">Univ.Prof. Dr.</prefix>              <given>Isabella</given>              <family>Stern</family>            </name>          </assignedPerson>        </assignedAuthor>      </author>      <entryRelationship typeCode="SUBJ" inversionInd="false">
        <observation classCode="OBS" moodCode="EVN">
          <!-- template 1.2.40.0.34.11.13.3.2 'Problem Entry Allergien ' (2016-11-06T17:03:02) -->
          <templateId root="1.2.40.0.34.11.13.3.2"/>          <id root="1.2.3.999" extension="--example only--"/>          <!-- ValueSet ELGA_AllergyOrIntoleranceType 1.2.40.0.34.10.177 -->
          <code code="419199007" displayName="Allergy to substance" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>          <text>
            <reference value="#typ1"/>          </text>          <statusCode code="completed"/>          <effectiveTime>
            <low value="20130400"/>          </effectiveTime>          <participant>
            <participantRole classCode="MANU">
              <playingEntity classCode="MMAT">
                <!-- ValueSet ELGA_AllergyOrIntoleranceAgent 1.2.40.0.34.10.180 -->
                <code code="1708977" displayName="METAMIZOL NATRIUM" codeSystem="1.2.40.0.34.5.156" codeSystemName="Medikation_AGES_Wirkstoffe _20170725">
                  <originalText>
                    <reference value="#alg1"/>                  </originalText>                </code>              </playingEntity>            </participantRole>          </participant>          <entryRelationship inversionInd="true" typeCode="MFST">
            <observation classCode="OBS" moodCode="EVN">
              <!-- template 1.2.40.0.34.11.13.3.15 'Problem Entry Allergien-Reaktion' (2017-07-13T21:39:19) -->
              <templateId root="1.2.40.0.34.11.13.3.15"/>              <id root="1.2.3.999" extension="--example only--"/>              <!-- ValueSet ELGA_Problemarten_2018 -->
              <code code="75326-9" displayName="Problem" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>              <statusCode code="completed"/>              <effectiveTime>
                <low nullFlavor="UNK"/>              </effectiveTime>              <value code="51599000" displayName="Oedema of larynx" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
                <originalText>
                  <reference value="#react1"/>                </originalText>              </value>              <entryRelationship typeCode="SUBJ" inversionInd="true">
                <observation classCode="OBS" moodCode="EVN">
                  <!-- template 1.2.40.0.34.11.13.3.21 'Severity Observation' (2017-08-20T12:08:35) -->
                  <templateId root="1.2.40.0.34.11.13.3.21"/>                  <id root="1.2.3.999" extension="--example only--"/>                  <code code="SEV"/>                  <statusCode code="completed"/>                  <!-- ValueSet ELGA_ProblemSeverity 1.2.40.0.34.10.189 -->
                  <value hl7:type="CD" code="6736007" displayName="Moderate" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
                    <originalText>
                      <reference value="#sev1"/>                    </originalText>                  </value>                </observation>              </entryRelationship>            </observation>          </entryRelationship>          <entryRelationship typeCode="SUBJ" inversionInd="true">
            <observation classCode="OBS" moodCode="EVN">
              <!-- template 1.2.40.0.34.11.13.3.18 'Criticality Observation' (2017-08-10T19:52:16) -->
              <templateId root="1.2.40.0.34.11.13.3.18"/>              <code code="82606-5" codeSystem="2.16.840.1.113883.6.1"/>              <statusCode code="completed"/>              <!-- ValueSet ELGA_CriticalityObservationValue 1.2.40.0.34.10.182 -->
              <value hl7:type="CD" code="CRITH" displayName="High criticality" codeSystem="2.16.840.1.113883.5.1063" codeSystemName="Observation Value">
                <originalText>
                  <reference value="#crit1"/>                </originalText>              </value>            </observation>          </entryRelationship>          <entryRelationship typeCode="SUBJ" inversionInd="true">
            <observation classCode="OBS" moodCode="EVN">
              <!-- template 1.2.40.0.34.11.13.3.19 'Certainty Observation' (2017-08-10T20:25:54) -->
              <templateId root="1.2.40.0.34.11.13.3.19"/>              <!-- LOINC Code not yet defined -->
              <code code="NEW-LOINC-CERTAINTY" displayName="NEW-LOINC-CERTAINTY" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>              <statusCode code="completed"/>              <!-- ValueSet ELGA_ConditionVerificationStatus 1.2.40.0.34.10.184 -->
              <value hl7:type="CD" code="confirmed" displayName="confirmed" codeSystem="2.16.840.1.113883.4.642.3.115" codeSystemName="AllergyIntoleranceVerificationStatus">
                <originalText>
                  <reference value="#cert1"/>                </originalText>              </value>            </observation>          </entryRelationship>          <entryRelationship typeCode="REFR" inversionInd="false">
            <observation classCode="OBS" moodCode="EVN">
              <!-- template 1.2.40.0.34.11.13.3.14 'Allergy Status Observation' (2017-07-13T21:15:15) -->
              <templateId root="1.2.40.0.34.11.13.3.14"/>              <code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>              <statusCode code="completed"/>              <!-- ValueSet ELGA_AllergyStatusCode 1.2.40.0.34.10.183 -->
              <value hl7:type="CD" code="active" displayName="active" codeSystem="2.16.840.1.113883.4.642.3.155" codeSystemName="Condition Clinical Status Codes"/>              <originalText>
                <reference value="#status1"/>              </originalText>            </observation>          </entryRelationship>        </observation>      </entryRelationship>      <reference>
        <externalDocument classCode="DOC" moodCode="EVN">
          <!-- template 1.2.40.0.34.11.13.3.17 'ELGA ExternalDocument' (2017-08-09T10:55:40) -->
          <id root="1.2.3.999" extension="--example only--"/>          <!-- ValueSet HL7-at_XDS-Dokumentenklassen -->
          <code code="11490-0" displayName="Physician Discharge summary" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>          <text>
            <reference value="#doc1"/>          </text>        </externalDocument>      </reference>    </act>  </entry>  <entry typeCode="DRIV">
    <!-- template 1.2.40.0.34.11.13.3.1 'Allergien und Unverträglichkeiten Entry' (dynamic) -->
    <act>
      <templateId root="1.2.40.0.34.11.13.3.1"/>      <id root="1.2.3.999" extension="--example only--"/>      <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>      <statusCode code="active"/>      <effectiveTime>
        <low value="20021200"/>      </effectiveTime>      <informant>
        <!-- template 1.2.40.0.34.11.13.3.20 'Informant (Body) PS' (2017-08-10T20:49:25) -->
        <relatedEntity classCode="PRS">
          <code code="SELF" displayName="self" codeSystem="1.2.40.0.34.10.17" codeSystemName="ELGA_PersonalRelationship"/>        </relatedEntity>      </informant>      <entryRelationship typeCode="SUBJ" inversionInd="false">
        <observation classCode="OBS" moodCode="EVN">
          <!-- template 1.2.40.0.34.11.13.3.2 'Problem Entry Allergien ' (2016-11-06T17:03:02) -->
          <id root="1.2.3.999" extension="--example only--"/>          <code code="X-Intolerance" displayName="Intolerance to substance" codeSystem="2.16.840.1.113883.3.1937.777.13.5.999.1" codeSystemName="hl7ips-codesystem"/>          <text>
            <reference value="#typ2"/>          </text>          <statusCode code="completed"/>          <effectiveTime>
            <low value="20021200"/>          </effectiveTime>          <participant>
            <!-- template 1.2.40.0.34.11.13.3.3 'Participant Allergie' (2016-11-06T17:53:23) -->
            <participantRole classCode="MANU">
              <playingEntity classCode="MMAT">
                <!-- ValueSet ELGA_AllergyOrIntoleranceAgent 1.2.40.0.34.10.180 -->
                <code code="256349002" displayName="Peanut - dietary" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
                  <originalText>
                    <reference value="#alg2"/>                  </originalText>                </code>              </playingEntity>            </participantRole>          </participant>          <entryRelationship typeCode="MFST" inversionInd="true">
            <observation classCode="OBS" moodCode="EVN">
              <!-- template 1.2.40.0.34.11.13.3.15 'Problem Entry Allergien-Reaktion' (2017-07-13T21:39:19) -->
              <templateId root="1.2.40.0.34.11.13.3.15"/>              <id root="1.2.3.999" extension="--example only--"/>              <!-- ValueSet ELGA_Problemarten_2018 -->
              <code code="75326-9" displayName="Problem" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>              <statusCode code="completed"/>              <effectiveTime>
                <low nullFlavor="UNK"/>              </effectiveTime>              <!-- ValueSet ELGA_AllergyReaction 1.2.40.0.34.10.181 -->
              <value code="62315008" displayName="Diarrhoea" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
                <originalText>
                  <reference value="#react2"/>                </originalText>                <translation/>              </value>              <entryRelationship typeCode="SUBJ" inversionInd="true">
                <observation classCode="OBS" moodCode="EVN">
                  <!-- template 1.2.40.0.34.11.13.3.21 'Severity Observation' (2017-08-20T12:08:35) -->
                  <templateId root="1.2.40.0.34.11.13.3.21"/>                  <id root="1.2.3.999" extension="--example only--"/>                  <code code="SEV"/>                  <statusCode code="completed"/>                  <!-- ValueSet ELGA_ProblemSeverity 1.2.40.0.34.10.189 -->
                  <value hl7:type="CD" code="6736007" displayName="Moderate" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
                    <originalText>
                      <reference value="#sev2"/>                    </originalText>                  </value>                </observation>              </entryRelationship>            </observation>            <observation classCode="OBS" moodCode="EVN">
              <!-- template 1.2.40.0.34.11.13.3.15 'Problem Entry Allergien-Reaktion' (2017-07-13T21:39:19) -->
              <templateId root="1.2.40.0.34.11.13.3.15"/>              <id root="1.2.3.999" extension="--example only--"/>              <!-- ValueSet ELGA_Problemarten_2018 -->
              <code code="75326-9" displayName="Problem" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>              <statusCode code="completed"/>              <effectiveTime>
                <low nullFlavor="UNK"/>              </effectiveTime>              <!-- ValueSet ELGA_AllergyReaction 1.2.40.0.34.10.181 -->
              <value code="126485001" displayName="Urticaria" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
                <originalText>
                  <reference value="#react3"/>                </originalText>              </value>              <entryRelationship typeCode="SUBJ" inversionInd="true">
                <observation classCode="OBS" moodCode="EVN">
                  <!-- template 1.2.40.0.34.11.13.3.21 'Severity Observation' (2017-08-20T12:08:35) -->
                  <templateId root="1.2.40.0.34.11.13.3.21"/>                  <id root="1.2.3.999" extension="--example only--"/>                  <code code="SEV"/>                  <statusCode code="completed"/>                  <!-- ValueSet ELGA_ProblemSeverity 1.2.40.0.34.10.189 -->
                  <value hl7:type="CD" code="24484000" displayName="Severe" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
                    <originalText>
                      <reference value="#sev3"/>                    </originalText>                  </value>                </observation>              </entryRelationship>            </observation>          </entryRelationship>          <entryRelationship typeCode="SUBJ" inversionInd="true">
            <observation classCode="OBS" moodCode="EVN">
              <!-- template 1.2.40.0.34.11.13.3.18 'Criticality Observation' (2017-08-10T19:52:16) -->
              <templateId root="1.2.40.0.34.11.13.3.18"/>              <code code="82606-5" codeSystem="2.16.840.1.113883.6.1"/>              <statusCode code="completed"/>              <!-- ValueSet ELGA_CriticalityObservationValue 1.2.40.0.34.10.182 -->
              <value hl7:type="CD" code="CRITL" codeSystem="2.16.840.1.113883.5.1063" codeSystemName="Observation Value">
                <originalText>
                  <reference value="#crit2"/>                </originalText>              </value>            </observation>          </entryRelationship>          <entryRelationship typeCode="SUBJ" inversionInd="true">
            <observation classCode="OBS" moodCode="EVN">
              <!-- template 1.2.40.0.34.11.13.3.19 'Certainty Observation' (2017-08-10T20:25:54) -->
              <templateId root="1.2.40.0.34.11.13.3.19"/>              <code code="t.b.d.NEW-LOINC-CERTAINTY" codeSystem="2.16.840.1.113883.6.1"/>              <statusCode code="completed"/>              <!-- ValueSet ELGA_ConditionVerificationStatus 1.2.40.0.34.10.184 -->
              <value hl7:type="CD" code="confirmed" displayName="confirmed" codeSystem="2.16.840.1.113883.4.642.3.115" codeSystemName="AllergyIntoleranceVerificationStatus">
                <originalText>
                  <reference value="#cert2"/>                </originalText>              </value>            </observation>          </entryRelationship>          <entryRelationship typeCode="REFR" inversionInd="false">
            <observation classCode="OBS" moodCode="EVN">
              <!-- template 1.2.40.0.34.11.13.3.14 'Allergy Status Observation' (2017-07-13T21:15:15) -->
              <templateId root="1.2.40.0.34.11.13.3.14"/>              <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>              <statusCode code="completed"/>              <!-- ValueSet ELGA_AllergyStatusCode 1.2.40.0.34.10.183 -->
              <value hl7:type="CD" code="active" codeSystem="2.16.840.1.113883.4.642.3.155" codeSystemName="Condition Clinical Status Codes">
                <originalText>
                  <reference value="#status2"/>                </originalText>              </value>            </observation>          </entryRelationship>        </observation>      </entryRelationship>    </act>  </entry>  <entry typeCode="DRIV">
    <!-- template 1.2.40.0.34.11.13.3.1 'Allergien und Unverträglichkeiten Entry' (dynamic) -->
    <act>
      <templateId root="1.2.40.0.34.11.13.3.1"/>      <id root="1.2.3.999" extension="--example only--"/>      <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>      <statusCode code="active"/>      <effectiveTime>
        <low nullFlavor="UNK"/>      </effectiveTime>      <entryRelationship typecode="SUBJ" inversionInd="false">
        <observation classCode="OBS" moodCode="EVN">
          <!-- template 1.2.40.0.34.11.13.3.2 'Problem Entry Allergien ' (2016-11-06T17:03:02) -->
          <templateId root="1.2.40.0.34.11.13.3.2"/>          <id root="1.2.3.999" extension="--example only--"/>          <!-- ValueSet ELGA_AllergyOrIntoleranceType 1.2.40.0.34.10.177 -->
          <code code="418038007" displayName="Propensity to adverse reactions to substance" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>          <text>
            <reference value="#typ3"/>          </text>          <statusCode code="completed"/>          <effectiveTime>
            <low nullFlavor="UNK"/>          </effectiveTime>          <participant>
            <!-- template 1.2.40.0.34.11.13.3.3 'Participant Allergie' (2016-11-06T17:53:23) -->
            <participantRole classCode="MANU">
              <playingEntity classCode="MMAT">
                <!-- ValueSet ELGA_AllergyOrIntoleranceAgent 1.2.40.0.34.10.180 -->
                <code code="102262009" displayName="Chocolate" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
                  <originalText>
                    <reference value="#alg3"/>                  </originalText>                </code>              </playingEntity>            </participantRole>          </participant>        </observation>      </entryRelationship>    </act>  </entry></section>
Item DT Kard Konf Beschreibung Label
hl7:section
 (Alldotsten)
hl7:templateId
 II 1 … 1 M (Alldotsten)
@root
 uid 1 … 1 F 1.2.40.0.34.11.13.2.1
hl7:id
 II 0 … 1 Eindeutige ID der Sektion (optional) (Alldotsten)
hl7:code
 CE (extensible) 1 … 1 M (Alldotsten)
@code
 CONF 1 … 1 F 48765-2
@codeSystem
 1 … 1 F 2.16.840.1.113883.6.1 (LOINC)
hl7:title
 ST 1 … 1 M (Alldotsten)
  CONF
Elementinhalt muss "Allergien und Intoleranzen" sein
hl7:text
 SD.TEXT 1 … 1 M Der Text enthält relevante Allergien oder Intoleranzen des Patienten in tabellarischer Darstellung.  (Alldotsten)
hl7:author
 0 … * Author der enthaltenen Information (GDA)
Beinhaltet 1.2.40.0.34.11.13.3.16 Author (Body) PS (DYNAMIC) 		(Alldotsten)
treeblank wo [hl7:assignedAuthor]
hl7:informant
 0 … * Quelle der Information. Name der Person und ihre Beziehung zum Patienten (Patient oder Angehöriger, Auskunftsperson - nicht-GDA)
Beinhaltet 1.2.40.0.34.11.13.3.20 Informant (Body) PS (DYNAMIC) 		(Alldotsten)
hl7:entry
 1 … * R Enthält die codierte Angabe der Allergien und Intoleranzen
Beinhaltet 1.2.40.0.34.11.13.3.1 Allergien und Intoleranzen Entry (DYNAMIC) 		(Alldotsten)
treeblank wo [hl7:act [hl7:templateId [@root = '1.2.40.0.34.11.13.3.1']]]
@typeCode
 cs 1 … 1 F DRIV
hl7:component
 0 … * Optionale Subsections zur Angabe von Übersetzungen des   Elements 
Beinhaltet 1.2.40.0.34.11.13.2.18 Übersetzung (DYNAMIC) 		(Alldotsten)
treeblank wo [hl7:section [hl7:templateId [@root = '1.2.40.0.34.11.13.2.18']]]
@typeCode
 cs 0 … 1 F COMP
@contextConductionInd
 cs 0 … 1 F true