<?xml version="1.0" encoding="iso-8859-1"?>
<?xml-stylesheet type="text/xsl" href="../../xsl/CDA.xsl"?>
<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
	<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040" />
	<id root="1.2.3.4.5.1" extension="01877.20070920.1639" />
	<code code="18842-5" codeSystem="2.16.840.1.113883.6.1" />
	<title>
		Entlassungskurzbrief der Deutschen Rentenversicherung Bund
	</title>
	<effectiveTime value="200709201639" />
	<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" />
	<recordTarget>
		<patientRole>
			<id extension="I01877" root="1.2.3.4.5" />
			<addr>
				<streetName>
					Am Himmelreich
				</streetName>
				<houseNumber>
					77
				</houseNumber>
				<postalCode>
					98527
				</postalCode>
				<city>
					Suhl
				</city>
			</addr>
			<telecom use="HP" value="tel:" />
			<patient>
				<name>
					<given>
						Gilbert
					</given>
					<family>
						Gildner
					</family>
				</name>
				<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" />
				<birthTime value="19610806" />
			</patient>
			<providerOrganization>
				<telecom use="WP" value="tel:0332-4556" />
				<telecom use="WP" value="fax:0332-45577" />
				<addr>
					<streetName>
						Zempiner Steig
					</streetName>
					<houseNumber>
						4
					</houseNumber>
					<postalCode>
						15266
					</postalCode>
					<city>
						Berlin
					</city>
				</addr>
			</providerOrganization>
		</patientRole>
	</recordTarget>
	<author>
		<time value="20070920" />
		<assignedAuthor>
			<id extension="a0082373" root="9.8.7.6" />
			<assignedPerson>
				<name>
					<given>
						
					</given>
					<family>
						Test13 PNT1                   
					</family>
				</name>
			</assignedPerson>
			<representedOrganization>
				<name>
					K30 auf 81355
				</name>
				<telecom use="WP" value="tel:0332-4556" />
				<telecom use="WP" value="fax:0332-45577" />
				<addr>
					<streetName>
						Zempiner Steig
					</streetName>
					<houseNumber>
						4
					</houseNumber>
					<postalCode>
						15266
					</postalCode>
					<city>
						Berlin
					</city>
				</addr>
			</representedOrganization>
		</assignedAuthor>
	</author>
	<custodian>
		<assignedCustodian>
			<representedCustodianOrganization>
				<id extension="269770818" root="1.2.276.0.76.4.5" />
				<name>
					K30 auf 81355
				</name>
				<telecom use="WP" value="tel:0332-4556" />
				<addr>
					<streetName>
						Zempiner Steig
					</streetName>
					<houseNumber>
						4
					</houseNumber>
					<postalCode>
						15266
					</postalCode>
					<city>
						Berlin
					</city>
				</addr>
			</representedCustodianOrganization>
		</assignedCustodian>
	</custodian>
	<informationRecipient typeCode="PRCP">
		<intendedRecipient>
			<id extension="7.1" root="99.88.10.1.4" />
			<informationRecipient>
				<name>
					<given>
						
					</given>
					<family>
						
					</family>
				</name>
			</informationRecipient>
			<receivedOrganization>
				<telecom use="WP" value="tel:" />
				<addr>
					<streetName>
						
					</streetName>
					<houseNumber>
						
					</houseNumber>
					<postalCode>
						
					</postalCode>
					<city>
						
					</city>
				</addr>
			</receivedOrganization>
		</intendedRecipient>
	</informationRecipient>
	<legalAuthenticator>
		<time value="20070920" />
		<signatureCode code="I" />
		<assignedEntity>
			<id extension="a0012345" root="9.8.7.6" />
			<assignedPerson>
				<name>
					<prefix qualifier="AC">
						Prof. Dr.
					</prefix>
					<given>
						Hugo
					</given>
					<family>
						Reinhardt
					</family>
				</name>
			</assignedPerson>
			<representedOrganization>
				<name>
					K30 auf 81355
				</name>
				<telecom use="WP" value="tel:0332-4556" />
				<telecom use="WP" value="fax:0332-45577" />
				<addr>
					<streetName>
						Zempiner Steig
					</streetName>
					<houseNumber>
						4
					</houseNumber>
					<postalCode>
						15266
					</postalCode>
					<city>
						Berlin
					</city>
				</addr>
			</representedOrganization>
		</assignedEntity>
	</legalAuthenticator>
	<componentOf>
		<encompassingEncounter>
			<code code="IMP" codeSystem="2.16.840.1.113883.5.4" />
			<effectiveTime>
				<low value="20070326" />
				<high value="20070813" inclusive="true" />
			</effectiveTime>
		</encompassingEncounter>
	</componentOf>
	<component>
		<structuredBody>
			<component>
				<section>
					<code code="X-SALUT" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
					<text>
						Gilbert Gildner, geboren am 06.08.1961, wohnhaft Am Himmelreich 77 in 98527 Suhl, befand sich in der Zeit vom 26.03.2007 bis zum 13.08.2007 in einer 
stationären Reha-Maßnahme im K30 auf 81355.					</text>
				</section>
			</component>
			<component>
				<section>
					<code code="8651-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
					<title>
						Diagnosen mit ICD 10
					</title>
					<text>
						<table>
							<thead>
								<tr>
									<th>
										ICD Code
									</th>
									<th>
										Zusatz
									</th>
									<th>
										Sicherheit
									</th>
									<th>
										Diagnose
									</th>
									<th>
										Ergebnis
									</th>
								</tr>
							</thead>
							<tbody>
								<tr>
									<td>
										I10.90
									</td>
									<td>
										U
									</td>
									<td>
										G
									</td>
									<td>
										<content ID="diag-1">
											Hypertonus
										</content>
									</td>
									<td>
									</td>
								</tr>
								<tr>
									<td>
										E78.5
									</td>
									<td>
										U
									</td>
									<td>
										G
									</td>
									<td>
										<content ID="diag-2">
											Hyperlipoprozeinämie
										</content>
									</td>
									<td>
									</td>
								</tr>
								<tr>
									<td>
										E14.40
									</td>
									<td>
										U
									</td>
									<td>
										G
									</td>
									<td>
										<content ID="diag-3">
											Diabetis mellitus
										</content>
									</td>
									<td>
									</td>
								</tr>
								<tr>
									<td>
										R48.1
									</td>
									<td>
										L
									</td>
									<td>
										G
									</td>
									<td>
										<content ID="diag-4">
											Babinski
										</content>
									</td>
									<td>
									</td>
								</tr>
							</tbody>
						</table>
					</text>
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<code code="DISDX" codeSystem="2.16.840.1.113883.3.7.1.16" />
							<statusCode code="completed" />
							<effectiveTime>
								<low value="1639" />
							</effectiveTime>
							<value xsi:type="CD" code="I1090" codeSystem="1.2.276.0.76.5.311" codeSystemName="ICD10gm2006">
								<originalText>
									<reference value="diag-1" />
								</originalText>
								<qualifier>
									<name code="8" codeSystem="2.16.840.1.113883.3.7.1" />
									<value code="G" codeSystem="2.16.840.1.113883.3.7.1.8" />
								</qualifier>
								<qualifier>
									<name code="8" codeSystem="2.16.840.1.113883.3.7.1" />
									<value code="U" codeSystem="2.16.840.1.113883.3.7.1.7" />
								</qualifier>
							</value>
						</observation>
					</entry>
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<code code="DISDX" codeSystem="2.16.840.1.113883.3.7.1.16" />
							<statusCode code="completed" />
							<effectiveTime>
								<low value="1639" />
							</effectiveTime>
							<value xsi:type="CD" code="E785" codeSystem="1.2.276.0.76.5.311" codeSystemName="ICD10gm2006">
								<originalText>
									<reference value="diag-2" />
								</originalText>
								<qualifier>
									<name code="8" codeSystem="2.16.840.1.113883.3.7.1" />
									<value code="G" codeSystem="2.16.840.1.113883.3.7.1.8" />
								</qualifier>
								<qualifier>
									<name code="8" codeSystem="2.16.840.1.113883.3.7.1" />
									<value code="U" codeSystem="2.16.840.1.113883.3.7.1.7" />
								</qualifier>
							</value>
						</observation>
					</entry>
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<code code="DISDX" codeSystem="2.16.840.1.113883.3.7.1.16" />
							<statusCode code="completed" />
							<effectiveTime>
								<low value="1639" />
							</effectiveTime>
							<value xsi:type="CD" code="E1440" codeSystem="1.2.276.0.76.5.311" codeSystemName="ICD10gm2006">
								<originalText>
									<reference value="diag-3" />
								</originalText>
								<qualifier>
									<name code="8" codeSystem="2.16.840.1.113883.3.7.1" />
									<value code="G" codeSystem="2.16.840.1.113883.3.7.1.8" />
								</qualifier>
								<qualifier>
									<name code="8" codeSystem="2.16.840.1.113883.3.7.1" />
									<value code="U" codeSystem="2.16.840.1.113883.3.7.1.7" />
								</qualifier>
							</value>
						</observation>
					</entry>
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<code code="DISDX" codeSystem="2.16.840.1.113883.3.7.1.16" />
							<statusCode code="completed" />
							<effectiveTime>
								<low value="1639" />
							</effectiveTime>
							<value xsi:type="CD" code="R481" codeSystem="1.2.276.0.76.5.311" codeSystemName="ICD10gm2006">
								<originalText>
									<reference value="diag-4" />
								</originalText>
								<qualifier>
									<name code="8" codeSystem="2.16.840.1.113883.3.7.1" />
									<value code="G" codeSystem="2.16.840.1.113883.3.7.1.8" />
								</qualifier>
								<qualifier>
									<name code="8" codeSystem="2.16.840.1.113883.3.7.1" />
									<value code="L" codeSystem="2.16.840.1.113883.3.7.1.7" />
								</qualifier>
							</value>
						</observation>
					</entry>
				</section>
			</component>
			<component>
				<section>
					<code code="10183-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
					<title>
						Medikation
					</title>
					<text>
						ASS 100, Captocomp 30/25, Beloc Zok mite, Molsidomin ret., Cranoc 80, Allopurinol 100, Metformin 850, Actos 30, Salbutamol DA
					</text>
				</section>
			</component>
			<component>
				<section>
					<code code="8648-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
					<title>
						Therapieverlauf / Bemerkungen
					</title>
					<text>
						Leichte 
Arbeiten sind zumutbar.					</text>
				</section>
			</component>
			<component>
				<section>
					<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
					<title>
						Therapieempfehlungen / Erläuerungen
					</title>
					<text>
						<list>
							<item>
								Funktionstraining
							</item>
							<item>
								Gewichtsreduktion
							</item>
							<item>
								Rehabilitationssport
							</item>
						</list>
<paragraph />
Die atherogenen Risikofaktoren sind derzeit gut eingestellt, die Blutz uckerwerte bedürfen weiterer Kontrollen. Hinweise auf eine Progression der koronaren Herzerkrankung ergaben sich nicht.					</text>
				</section>
			</component>
			<component>
				<section>
					<code code="X-ATWRK" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
					<title>
						Arbeitsfähigkeit
					</title>
					<text>
						Bei Entlassung: 
Arbeitsfähig					</text>
				</section>
			</component>
		</structuredBody>
	</component>
</ClinicalDocument>
