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draft Template  Glasgow Coma Scale

Template 1.2.276.0.76.10.4034 - GlasgowComaScale
Id 1.2.276.0.76.10.4034
Version gültig ab 2014‑09‑16 Status draft In Entwicklung
Klassifikation CDA Entry Level Template
Kontext Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4034
Offen/Geschlossen Offen (auch andere als die definierten Elemente sind erlaubt)
Beschreibung Glasgow Coma Scale (GCS) als Summe und mit den drei Achsen Augenöffnen, verbale Antwort und motorische Antwort
Assoziiert mit
Assoziiert mit 15 Konzepte
Id Name Datensatz
aktin-dataelement2015(2)-10007 Glasgow Coma Scale (GCS) AKTIN-Datensatz
aktin-dataelement2015(2)-13 GCS Augenöffnen AKTIN-Datensatz
aktin-dataelement2015(2)-14 GCS verbale Antwort AKTIN-Datensatz
aktin-dataelement2015(2)-16 GCS motorische Antwort AKTIN-Datensatz
aktin-dataelement2015(2)-17 GCS Summe AKTIN-Datensatz
aktin-dataelement2015(1)-10007 Glasgow Coma Scale (GCS) AKTIN-Datensatz
aktin-dataelement2015(1)-13 GCS Augenöffnen AKTIN-Datensatz
aktin-dataelement2015(1)-14 GCS verbale Antwort AKTIN-Datensatz
aktin-dataelement2015(1)-16 GCS motorische Antwort AKTIN-Datensatz
aktin-dataelement2015(1)-17 GCS Summe AKTIN-Datensatz
aktin-dataelement2014(1)-10007 Glasgow Coma Scale (GCS) AKTIN-Datensatz
aktin-dataelement2014(1)-13 GCS Augenöffnen AKTIN-Datensatz
aktin-dataelement2014(1)-14 GCS verbale Antwort AKTIN-Datensatz
aktin-dataelement2014(1)-16 GCS motorische Antwort AKTIN-Datensatz
aktin-dataelement2014(1)-17 GCS Summe AKTIN-Datensatz
Benutzt von / Benutzt
Benutzt von / Benutzt 3 Templates
Benutzt von Template-Id als Name Version
1.2.276.0.76.10.3044 Containment VitalSignsSection Vitalparameter 2015‑09‑18
1.2.276.0.76.10.1015 link EmergencymedicineNoteCDAdocument Emergency medicine Note CDA document 2014‑09‑18
1.2.276.0.76.10.3044 Containment VitalSignsSection Vitalparameter 2014‑09‑16
Beziehung Spezialisierung: Template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Beispiel <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"/>
  <statusCode code="completed"/>
  <effectiveTime value="20141019"/>
  <value xsi:type="PQ" value="9" 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="3" 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="2" unit="{score}"/>
    </observation>  </entryRelationship></observation>
Item DT Kard Konf Beschreibung Label
hl7:observation
(GlasgowComaScale)
treetree @classCode
1 .. 1 F OBS
treetree @moodCode
1 .. 1 F EVN
  target Ziel der Konzept Id(s):
aktin-dataelement2014(1)-10007 Glasgow Coma Scale (GCS)
aktin-dataelement2015(1)-10007 Glasgow Coma Scale (GCS)
aktin-dataelement2015(2)-10007 Glasgow Coma Scale (GCS)
treetree hl7:templateId
II 1 .. 1 M (GlasgowComaScale)
treeblank treetree @root
1 .. 1 F 1.2.276.0.76.10.4034
treetree hl7:id
0 .. 1 R (GlasgowComaScale)
treetree hl7:code
CE 1 .. 1 M (GlasgowComaScale)
treeblank treetree @code
1 .. 1 F 9269-2
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
treetree hl7:statusCode
CS 1 .. 1 M (GlasgowComaScale)
treeblank treetree @code
1 .. 1 F completed
treetree hl7:text
ED 0 .. 1 Lediglich reference in den Text der zugehörigen Section (GlasgowComaScale)
treeblank treetree hl7:reference
URL 1 .. 1 (GlasgowComaScale)
treetree hl7:effectiveTime
TS 0 .. 1 R (GlasgowComaScale)
treetree hl7:value
PQ 1 .. 1 R (GlasgowComaScale)
treeblank treetree @value
1 .. 1 R
  Score
treeblank treetree @unit
1 .. 1 F {score}
  CONF
minInclude low boundary is "3"
-oder-
maxInclude high boundary is "15"
  target Ziel der Konzept Id(s):
aktin-dataelement2014(1)-17 GCS Summe
aktin-dataelement2015(1)-17 GCS Summe
aktin-dataelement2015(2)-17 GCS Summe
treetree hl7:entryRelationship
wo
[hl7:observation/hl7:code/@code='9267-6']
0 .. 1 C (GlasgowComaScale)
treeblank treetree @typeCode
1 .. 1 F COMP
treeblank treetree @contextConductionInd
1 .. 1 F true
treeblank treetree hl7:observation
1 .. 1 M (GlasgowComaScale)
treeblank treeblank treetree @classCode
1 .. 1 F OBS
treeblank treeblank treetree @moodCode
1 .. 1 F EVN
treeblank treeblank treetree hl7:code
CE 1 .. 1 M (GlasgowComaScale)
treeblank treeblank treeblank treetree @code
1 .. 1 F 9267-6
treeblank treeblank treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
treeblank treeblank treetree hl7:statusCode
CS 1 .. 1 M (GlasgowComaScale)
treeblank treeblank treeblank treetree @code
1 .. 1 F completed
treeblank treeblank treetree hl7:value
PQ 1 .. 1 R (GlasgowComaScale)
treeblank treeblank treeblank treetree @value
1 .. 1 R
  Score
treeblank treeblank treeblank treetree @unit
1 .. 1 F {score}
  CONF
minInclude low boundary is "1"
-oder-
maxInclude high boundary is "4"
  target Ziel der Konzept Id(s):
aktin-dataelement2014(1)-13 GCS Augenöffnen
aktin-dataelement2015(1)-13 GCS Augenöffnen
aktin-dataelement2015(2)-13 GCS Augenöffnen
treetree hl7:entryRelationship
wo
[hl7:observation/hl7:code/@code='9270-0']
0 .. 1 C (GlasgowComaScale)
treeblank treetree @typeCode
1 .. 1 F COMP
treeblank treetree @contextConductionInd
1 .. 1 F true
treeblank treetree hl7:observation
1 .. 1 M (GlasgowComaScale)
treeblank treeblank treetree @classCode
1 .. 1 F OBS
treeblank treeblank treetree @moodCode
1 .. 1 F EVN
treeblank treeblank treetree hl7:code
CE 1 .. 1 M (GlasgowComaScale)
treeblank treeblank treeblank treetree @code
1 .. 1 F 9270-0
treeblank treeblank treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
treeblank treeblank treetree hl7:statusCode
CS 1 .. 1 M (GlasgowComaScale)
treeblank treeblank treeblank treetree @code
1 .. 1 F completed
treeblank treeblank treetree hl7:value
PQ 1 .. 1 R (GlasgowComaScale)
treeblank treeblank treeblank treetree @value
1 .. 1 R
  Score
treeblank treeblank treeblank treetree @unit
1 .. 1 F {score}
  CONF
minInclude low boundary is "1"
-oder-
maxInclude high boundary is "5"
  target Ziel der Konzept Id(s):
aktin-dataelement2014(1)-14 GCS verbale Antwort
aktin-dataelement2015(1)-14 GCS verbale Antwort
aktin-dataelement2015(2)-14 GCS verbale Antwort
treetree hl7:entryRelationship
wo
[hl7:observation/hl7:code/@code='9268-4']
0 .. 1 C (GlasgowComaScale)
treeblank treetree @typeCode
1 .. 1 F COMP
treeblank treetree @contextConductionInd
1 .. 1 F true
treeblank treetree hl7:observation
1 .. 1 M (GlasgowComaScale)
treeblank treeblank treetree @classCode
1 .. 1 F OBS
treeblank treeblank treetree @moodCode
1 .. 1 F EVN
treeblank treeblank treetree hl7:code
CE 1 .. 1 M (GlasgowComaScale)
treeblank treeblank treeblank treetree @code
1 .. 1 F 9268-4
treeblank treeblank treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
treeblank treeblank treetree hl7:statusCode
CS 1 .. 1 M (GlasgowComaScale)
treeblank treeblank treeblank treetree @code
1 .. 1 F completed
treeblank treeblank treetree hl7:value
PQ 1 .. 1 R (GlasgowComaScale)
treeblank treeblank treeblank treetree @value
1 .. 1 R
  Score
treeblank treeblank treeblank treetree @unit
1 .. 1 F {score}
  CONF
minInclude low boundary is "1"
-oder-
maxInclude high boundary is "6"
  target Ziel der Konzept Id(s):
aktin-dataelement2014(1)-16 GCS motorische Antwort
aktin-dataelement2015(1)-16 GCS motorische Antwort
aktin-dataelement2015(2)-16 GCS motorische Antwort