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# Template Problem Status Observation Entry

Id | 1.2.40.0.34.11.13.3.13 ref elgabbr- | Gültigkeit ab | 2017‑07‑13 20:51:44 Andere Versionen mit dieser Id: ProblemStatusObservationEntry vom 2017‑07‑13 21:04:49 ProblemStatusObservationEntry vom 2017‑07‑13 21:03:14
Status | Entwurf | Versions-Label | 0.1
Name | ProblemStatusObservationEntry | Bezeichnung | Problem Status Observation Entry
Beschreibung
Klinischer Status des Problems
Kontext | Elternknoten des Template-Element mit Id 1.2.40.0.34.11.13.3.13
Klassifikation | CDA Entry Level Template
Offen/Geschlossen | Offen (auch andere als die definierten Elemente sind erlaubt)
Beziehung | Adaptation: Template 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 Entry Problem Status Observation (2013‑12‑20) ref epsos-
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>
Item | DT | Kard | Konf | Beschreibung | Label
--- | --- | --- | --- | --- | ---
hl7:observation |  |  |  |  |
@classCode | cs | 0 … 1 | F | OBS
@moodCode | cs | 0 … 1 | F | EVN
hl7:templateId | II | 1 … 1 | M |  |
@root | uid | 1 … 1 | F | 1.2.40.0.34.11.13.3.13
hl7:templateId | II | 1 … 1 | R |  |
@root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.1.57
hl7:templateId | II | 1 … 1 | R |  |
@root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.1.50
hl7:templateId | II | 1 … 1 | R |  |
@root | uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.5.3.1.4.1.1
hl7:code | CD | 1 … 1 | R | This observation is of clinical status, as indicated by the <code> element. This element must be present. |
@code | CONF | 0 … 1 | F | 33999-4
@codeSystem | 0 … 1 | F | 2.16.840.1.113883.6.1 (LOINC)
@codeSystemName | 0 … 1 | F | LOINC
@displayName | 0 … 1 | F | Status
hl7:text | ED | 1 … 1 | M | 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. |
hl7:reference | TEL | 1 … 1 | M |  |
@value |  | 1 … 1 | R | Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
hl7:statusCode | CS | 1 … 1 | M | 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. |
@code | CONF | 1 … 1 | F | completed
hl7:value | CE.EPSOS | 1 … 1 | R | 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. |
| 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)