Template 2.16.756.5.30.1.1.10.3.14

Template Findings

Id 2.16.756.5.30.1.1.10.3.14 Effective Date valid from 2017‑09‑08 10:23:39

Status Draft Version Label 2017

Name FindingsSection Display Name Findings

Description Findings Section

Context Parent nodes of template element with id 2.16.756.5.30.1.1.10.3.14

Classification CDA Section Level Template

Open/Closed Open (other than defined elements are allowed)

Associated with

Associated with 1 concept

Id	Name	Data Set
cdachresp-dataelement-17	Befund	1

Used by / Uses

Used by 0 transactions and 2 templates, Uses 4 templates

Used by	as	Name	Version
2.16.756.5.30.1.1.10.1.2	Containment	EmergencyMedicalServiceProtocol (2017)	2017‑06‑13 17:19:29
2.16.756.5.30.1.1.10.1.2		EmergencyMedicalServiceProtocol (2017)	2017‑05‑31 17:19:29
	Circular reference found with cdachresp-template-document-2, please check
Uses	as	Name	Version
1.2.276.0.76.10.4034	Containment	Glasgow Coma Scale	DYNAMIC
2.16.756.5.30.1.1.10.4.64	Containment	Level of Responsiveness (AVPU) (2017)	DYNAMIC
2.16.756.5.30.1.1.10.4.82	Containment	Observation Airways (2017)	DYNAMIC
2.16.756.5.30.1.1.10.4.80	Containment	Observation Cardiac Arrest (2017)	DYNAMIC

Relationship Specialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)

Example

<section> <templateId root="2.16.756.5.30.1.1.10.3.14"/> <code code="1100006" codeSystem="2.16.756.5.30.1.143.5.1" displayName="Befund" codeSystemName="IVR Codesystem RESP"/> <title>Befund</title> <text> <paragraph> Blutdruck 120/80 mmHg gemessen am rechten Arm <br/> Schmerz 5 <br/> </paragraph> <table> <tbody> <tr> <th>GCS</th> </tr> <tr> <td ID="gcs1">Total 15 (Augenöffnung spontan 4/ verbale Antwort orientiert 5/ morot. Reaktion befolgt Antweisungen 6) um 12:25 </td> </tr> </tbody> </table> </text> <entry>  <observation classCode="OBS" moodCode="EVN"> <templateId root="1.2.276.0.76.10.4034"/> <id root="1.2.276.0.76.4.17.9814184919" extension="98C1EB7E-DC2D-4D1F-806A-2AD65EBA0351"/> <code code="9269-2" codeSystem="2.16.840.1.113883.6.1" displayName="Glasgow coma score total"/> <text> <reference value="#gcs1"/> </text> <statusCode code="completed"/> <effectiveTime value="20161210112500.0000+0100"/>  <value xsi:type="PQ" value="15" unit="{score}"/> <entryRelationship typeCode="COMP" contextConductionInd="true"> <observation classCode="OBS" moodCode="EVN"> <code code="9267-6" codeSystem="2.16.840.1.113883.6.1" displayName="Glasgow coma score eye opening"/> <statusCode code="completed"/>  <value xsi:type="PQ" value="4" unit="{score}"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP" contextConductionInd="true"> <observation classCode="OBS" moodCode="EVN"> <code code="9270-0" codeSystem="2.16.840.1.113883.6.1" displayName="Glasgow coma score verbal"/> <statusCode code="completed"/>  <value xsi:type="PQ" value="5" unit="{score}"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP" contextConductionInd="true"> <observation classCode="OBS" moodCode="EVN"> <code code="9268-4" codeSystem="2.16.840.1.113883.6.1" displayName="Glasgow coma score motor"/> <statusCode code="completed"/>  <value xsi:type="PQ" value="6" unit="{score}"/> </observation> </entryRelationship> </observation> </entry></section>

Item DT Card Conf Description Label

hl7:section (Finion)

cdachresp-dataelement-17

Befund

@classCode cs 0 … 1 F DOCSECT

@moodCode cs 0 … 1 F EVN

hl7:templateId II 1 … 1 M (Finion)

@root uid 1 … 1 F 2.16.756.5.30.1.1.10.3.14

hl7:code CE 1 … 1 M (Finion)

@code CONF 1 … 1 F 1100006

@codeSystem 1 … 1 F 2.16.756.5.30.1.143.5.1

@codeSystemName 1 … 1 F IVR Codesystem RESP

@displayName 1 … 1 F Befund

hl7:title

1 … 1

Fixed human readable title of this section.

[ge]: 'Befund'
[fr]: 'TODO'
[it]: 'TODO'
[en]: 'TODO'

The German title must read 'Befund'

(Fin

ion)

hl7:text SD.TEXT 1 … 1 M Human readable text of this section. (Finion)

hl7:entry 0 … 1 Contains 1.2.276.0.76.10.4034 Glasgow Coma Scale (DYNAMIC) (Finion)

where [hl7:observation [hl7:templateId [@root='1.2.276.0.76.10.4034']]]

hl7:entry 0 … 1 Contains 2.16.756.5.30.1.1.10.4.64 Level of Responsiveness (AVPU) (DYNAMIC) (Finion)

where [hl7:observation [hl7:templateId [@root='2.16.756.5.30.1.1.10.4.21'] and hl7:templateId [@root='2.16.756.5.30.1.1.10.4.64'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.13'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.13.2'] and hl7:templateId [@root='2.16.840.1.113883.10.20.1.31']]]

hl7:entry 0 … 1 Contains 2.16.756.5.30.1.1.10.4.82 Observation Airways (DYNAMIC) (Finion)

where [hl7:observation [hl7:templateId [@root='2.16.756.5.30.1.1.10.4.82']]]

hl7:entry 0 … 1 Contains 2.16.756.5.30.1.1.10.4.80 Observation Cardiac Arrest (DYNAMIC) (Finion)

where [hl7:observation [hl7:templateId [@root='2.16.756.5.30.1.1.10.4.80']]]

Template Findings