Polish National Implementation of HL7 CDA (plcda-)

eZdrowie - Projekt P1

Examples - [1] Skierowanie do szpitala psychiatrycznego

Skierowanie do szpitala psychiatrycznego [Show example]

<ClinicalDocument>
  <!-- Skierowanie do szpitala psychiatrycznego -->
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root="2.16.840.1.113883.3.4424.13.10.1.1"/>
  <templateId root="2.16.840.1.113883.3.4424.13.10.1.2"/>
  <templateId root="2.16.840.1.113883.3.4424.13.10.1.12" extension="1.2"/>
  <id extension="2345678" root="2.16.840.1.113883.3.4424.7.4.1" displayable="false"/>
  <code code="57832-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for diagnostic or specialist care Document">
    <translation code="02.10" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Skierowanie na badanie lub leczenie"/>
  </code>
  <title>Skierowanie do szpitala psychiatrycznego</title>
  <effectiveTime value="20130412"/>
  <confidentialityCode code="R" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="pl-PL"/>
  <setId extension="432231" root="2.16.840.1.113883.3.4424.7.4.2"/>
  <versionNumber value="1"/>
  <recordTarget>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.3"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.26"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.40"/>
    <patientRole>
      <id extension="12345" root="2.16.840.1.113883.3.4424.2.7.0.17.1" displayable="false"/>
      <id extension="62011699999" root="2.16.840.1.113883.3.4424.1.1.616" displayable="true"/>
      <addr>
        <city>Warszawa</city>
        <postalCode>01-134</postalCode>
        <streetName>Odkryta</streetName>
        <houseNumber>41</houseNumber>
        <unitID>12</unitID>
      </addr>
      <patient xsi:type="extPL:Patient">
        <name>
          <given>Jan</given>
          <given>Franciszek</given>
          <family>Kowalski</family>
        </name>
        <birthTime value="19620116"/>
        <birthplace>
          <place>
            <addr>
              <city>Warszawa</city>
            </addr>
          </place>
        </birthplace>
        <extPL:personalRelationship classCode="PRS">
          <extPL:templateId root="2.16.840.1.113883.3.4424.13.10.2.9"/>
          <extPL:templateId root="2.16.840.1.113883.3.4424.13.10.2.64"/>
          <extPL:code code="MTH" codeSystem="2.16.840.1.113883.5.111" displayName="Mother"/>
          <extPL:person classCode="PSN">
            <extPL:name>
              <given>Joanna</given>
            </extPL:name>
          </extPL:person>
        </extPL:personalRelationship>
        <extPL:personalRelationship classCode="PRS">
          <extPL:templateId root="2.16.840.1.113883.3.4424.13.10.2.9"/>
          <extPL:templateId root="2.16.840.1.113883.3.4424.13.10.2.65"/>
          <extPL:code code="FTH" codeSystem="2.16.840.1.113883.5.111" displayName="Father"/>
          <extPL:person classCode="PSN">
            <extPL:name>
              <given>Franciszek</given>
            </extPL:name>
          </extPL:person>
        </extPL:personalRelationship>
      </patient>
    </patientRole>
  </recordTarget>
  <author>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.4"/>
    <time value="20130412"/>
    <assignedAuthor>
      <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="false"/>
    </assignedAuthor>
  </author>
  <custodian>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.5"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.20"/>
    <assignedCustodian>
      <representedCustodianOrganization>
        <id root="2.16.840.1.113883.3.4424" assigningAuthorityName="CSIOZ" displayable="false"/>
      </representedCustodianOrganization>
    </assignedCustodian>
  </custodian>
  <legalAuthenticator>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.6"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.27"/>
    <time value="20130412"/>
    <signatureCode code="S"/>
    <assignedEntity xsi:type="extPL:AssignedEntity">
      <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="true"/>
      <code code="LEK" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Lekarz"/>
      <assignedPerson xsi:type="extPL:Person">
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/>
        <name>
          <prefix>lek.</prefix>
          <given>Piotr</given>
          <family>Nowak</family>
        </name>
        <extPL:qualifiedEntity classCode="QUAL">
          <extPL:templateId root="2.16.840.1.113883.3.4424.13.10.2.10"/>
          <extPL:code code="0718" codeSystem="2.16.840.1.113883.3.4424.11.3.3" displayName="neurologia"/>
        </extPL:qualifiedEntity>
        <extPL:qualifiedEntity classCode="QUAL">
          <extPL:templateId root="2.16.840.1.113883.3.4424.13.10.2.10"/>
          <extPL:code code="0726" codeSystem="2.16.840.1.113883.3.4424.11.3.3" displayName="radiologia i diagnostyka obrazowa"/>
        </extPL:qualifiedEntity>
      </assignedPerson>
      <representedOrganization>
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.2"/>
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.17"/>
        <id extension="1007-01" root="2.16.840.1.113883.3.4424.2.3.2" displayable="true"/>
        <name>Poradnia POZ</name>
        <telecom use="PUB" value="tel:22-1111123"/>
        <telecom use="PUB" value="fax:22-1111100"/>
        <addr>
          <postalCode>00-950</postalCode>
          <city>Warszawa</city>
          <streetName>Marszałkowska</streetName>
          <houseNumber>320</houseNumber>
        </addr>
        <asOrganizationPartOf>
          <wholeOrganization>
            <templateId root="2.16.840.1.113883.3.4424.13.10.2.2"/>
            <templateId root="2.16.840.1.113883.3.4424.13.10.2.16"/>
            <id extension="12345678901234" root="2.16.840.1.113883.3.4424.2.2.2" displayable="true"/>
            <name>NZOZ „POL-MED”</name>
            <asOrganizationPartOf>
              <wholeOrganization>
                <templateId root="2.16.840.1.113883.3.4424.13.10.2.2"/>
                <templateId root="2.16.840.1.113883.3.4424.13.10.2.14"/>
                <id extension="1007" root="2.16.840.1.113883.3.4424.2.3.1" displayable="true"/>
                <id extension="123456789" root="2.16.840.1.113883.3.4424.2.2.1" displayable="true"/>
                <name>POL-MED Sp. z o.o.</name>
              </wholeOrganization>
            </asOrganizationPartOf>
          </wholeOrganization>
        </asOrganizationPartOf>
      </representedOrganization>
      <extPL:boundedBy typeCode="PART">
        <extPL:templateId root="2.16.840.1.113883.3.4424.13.10.2.44"/>
        <extPL:reimbursementRelatedContract moodCode="EVN" classCode="CNTRCT">
          <extPL:id extension="123456" root="2.16.840.1.113883.3.4424.8.6.7"/>
          <extPL:bounding typeCode="PART">
            <extPL:reimburser classCode="UNDWRT">
              <extPL:id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/>
            </extPL:reimburser>
          </extPL:bounding>
        </extPL:reimbursementRelatedContract>
      </extPL:boundedBy>
    </assignedEntity>
  </legalAuthenticator>
  <component>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.8"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.28"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.41"/>
    <structuredBody>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.17"/>
          <code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social history"/>
          <text>
            <paragraph>
              <caption>Zamieszkuje:</caption>
               wspólnie z innymi osobami             </paragraph>
            <paragraph>
              <caption>Stan cywilny:</caption>
               żonaty             </paragraph>
            <paragraph>
              <caption>Zatrudnienie:</caption>
               na utrzymaniu innych osób             </paragraph>
            <paragraph>
              <caption>Wykształcenie:</caption>
               wyższe             </paragraph>
            <paragraph> Osoba badana jest ubezwłasnowolniona całkowicie. </paragraph>
          </text>
          <component>
            <section>
              <templateId root="2.16.840.1.113883.3.4424.13.10.3.3"/>
              <code code="10186-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Identifying information"/>
              <title>Dane o osobach będzących z mocy prawa uczestnikami postępowania sądowego (art. 46 ust. 1 ustawy z dnia 19.08.1994 o ochronie zdrowia psychicznego):</title>
              <text>
                <paragraph>
                  <caption>małżonek:</caption>
                   Joanna Kowalska, Odkryta 41 m. 12, Warszawa                 </paragraph>
              </text>
            </section>
          </component>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.18"/>
          <code code="10164-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of present illness"/>
          <text>
            <paragraph>
              <caption>Wywiad od osoby badanej:</caption>
               Lorem ipsum dolor sit amet, consectetur adipiscing elit. Quisque sed urna nibh. Donec lacus mi, varius sed ex at, elementum mattis mauris. In sit amet quam vel sem pellentesque euismod.             </paragraph>
            <paragraph>
              <caption>Wywiad od rodziny i innych osób:</caption>
               Lorem ipsum dolor sit amet, consectetur adipiscing elit. Quisque sed urna nibh. Donec lacus mi, varius sed ex at, elementum mattis mauris. In sit amet quam vel sem pellentesque euismod.             </paragraph>
          </text>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.19"/>
          <code code="29545-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Physical findings"/>
          <text>
            <paragraph>
              <caption>Ocena stanu fizycznego:</caption>
               Lorem ipsum dolor sit amet, consectetur adipiscing elit. Quisque sed urna nibh. Donec lacus mi, varius sed ex at, elementum mattis mauris. In sit amet quam vel sem pellentesque euismod.             </paragraph>
            <paragraph>
              <caption>Ocena stanu psychicznego:</caption>
               Lorem ipsum dolor sit amet, consectetur adipiscing elit. Quisque sed urna nibh. Donec lacus mi, varius sed ex at, elementum mattis mauris. In sit amet quam vel sem pellentesque euismod.             </paragraph>
          </text>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.20"/>
          <code code="29548-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis"/>
          <text>
            <paragraph>
              <caption>Rozpoznanie wstępne:</caption>
               Jakościowe zaburzenia świadomości. Urojenia prześladowania.             </paragraph>
          </text>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.21"/>
          <code code="57828-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescriptions"/>
          <text>
            <paragraph ID="ENC_1"> Kieruję pacjenta do szpitala psychiatrycznego. </paragraph>
          </text>
          <entry>
            <templateId root="2.16.840.1.113883.3.4424.13.10.4.11"/>
            <encounter classCode="ENC" moodCode="RQO">
              <code code="4700" codeSystem="2.16.840.1.113883.3.4424.11.2.4" displayName="Oddział psychiatryczny (ogólny)"/>
              <text>
                <reference value="#ENC_1"/>
              </text>
            </encounter>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.22"/>
          <code code="42349-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Reason for referral"/>
          <text>
            <paragraph>
              <caption>Stwierdzam, że:</caption>
               nieprzyjęcie osoby badanej do szpitala psychiatrycznego spowoduje pogorszenie stanu zdrowia psychicznego.             </paragraph>
          </text>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>