Polish National Implementation of HL7 CDA (plcda-)

eZdrowie - Projekt P1

Examples - [1] Konsultacja lekarska

Konsultacja neurologiczna [Show example]

<ClinicalDocument>
  <!-- Konsultacja lekarska - przykład 1 -->
  <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="2.16.840.1.113883.3.4424.13.10.1.15" extension="1.2"/>
  <id extension="2345678" root="2.16.840.1.113883.3.4424.2.7.0.7.1" displayable="false"/>
  <code code="11488-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Consult note">
    <translation code="05.00" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Konsultacja lekarska"/>
  </code>
  <title>Konsultacja neurologa</title>
  <effectiveTime value="20140906"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="pl-PL"/>
  <setId extension="432231" root="2.16.840.1.113883.3.4424.2.7.0.7.2"/>
  <versionNumber value="1"/>
  <recordTarget>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.3"/>
    <patientRole>
      <id extension="12345" root="2.16.840.1.113883.3.4424.2.7.0.17.1" displayable="false"/>
      <id extension="62091599999" 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>
        <name>
          <given>Jan</given>
          <given>Franciszek</given>
          <family>Kowalski</family>
        </name>
        <birthTime value="19620915"/>
      </patient>
      <providerOrganization classCode="ORG">
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.2"/>
        <id extension="1007" root="2.16.840.1.113883.3.4424.2.3.1" displayable="false"/>
      </providerOrganization>
    </patientRole>
  </recordTarget>
  <author>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.4"/>
    <time value="20140906"/>
    <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"/>
    <assignedCustodian>
      <representedCustodianOrganization>
        <id extension="1007" root="2.16.840.1.113883.3.4424.2.3.1" displayable="false"/>
      </representedCustodianOrganization>
    </assignedCustodian>
  </custodian>
  <legalAuthenticator>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.6"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.55"/>
    <time value="20140906"/>
    <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>
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/>
        <name>
          <prefix>dr n. med.</prefix>
          <given>Piotr</given>
          <family>Nowak</family>
        </name>
      </assignedPerson>
      <representedOrganization>
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.2"/>
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.15"/>
        <id extension="000000046985-01" root="2.16.840.1.113883.3.4424.2.4.53.1"/>
        <telecom use="PUB" value="tel:22-1111123"/>
        <telecom use="PUB" value="fax:22-1111100"/>
        <addr>
          <country>Polska</country>
          <postalCode>00-950</postalCode>
          <city>Warszawa</city>
          <streetName>Litewska</streetName>
          <houseNumber>18</houseNumber>
        </addr>
        <asOrganizationPartOf>
          <code code="L" codeSystem="2.16.840.1.113883.3.4424.11.3.19" codeSystemName="RODZ_PRAKTYKI" displayName="Praktyka lekarska"/>
          <wholeOrganization>
            <id extension="000000046985" root="2.16.840.1.113883.3.4424.2.4.53"/>
            <id extension="123456789" root="2.16.840.1.113883.3.4424.2.2.1" displayable="true"/>
            <name>Praktyka lekarska Jan Nowak</name>
          </wholeOrganization>
        </asOrganizationPartOf>
      </representedOrganization>
      <extPL:boundedBy typeCode="PART">
        <extPL:templateId root="2.16.840.1.113883.3.4424.13.10.2.44"/>
        <extPL:reimbursementRelatedContract classCode="CNTRCT" moodCode="EVN">
          <extPL:id extension="07-20048-33" root="2.16.840.1.113883.3.4424.8.6.7"/>
          <extPL:code/>
          <extPL:bounding typeCode="PART">
            <extPL:reimburser classCode="UNDWRT">
              <extPL:id extension="07" root="2.16.840.1.113883.3.4424.3.1"/>
            </extPL:reimburser>
          </extPL:bounding>
        </extPL:reimbursementRelatedContract>
      </extPL:boundedBy>
    </assignedEntity>
  </legalAuthenticator>
  <documentationOf typeCode="DOC">
    <serviceEvent classCode="ACT" moodCode="EVN">
      <templateId root="2.16.840.1.113883.3.4424.13.10.2.51"/>
      <code code="89.005" codeSystem="2.16.840.1.113883.3.4424.11.2.6" codeSystemName="ICD-9-PL" displayName="Konsultacja neurologiczna"/>
      <effectiveTime value="20140906"/>
    </serviceEvent>
  </documentationOf>
  <componentOf typeCode="COMP">
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.52"/>
    <encompassingEncounter classCode="ENC" moodCode="EVN">
      <code code="1220" codeSystem="2.16.840.1.113883.3.4424.11.2.4" displayName="Poradnia neurologiczna"/>
      <effectiveTime value="20140906"/>
    </encompassingEncounter>
  </componentOf>
  <component typeCode="COMP" contextConductionInd="true">
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.8"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.56"/>
    <structuredBody classCode="DOCBODY" moodCode="EVN">
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.30"/>
          <code code="10164-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of present illness"/>
          <title>Wywiad lekarski</title>
          <text>
            <paragraph> Przed tygodniem pacjent zgłosił się do internisty z powodu znacznego nasilenia bólów głowy w okolicy skroniowej. Ból ma charakter rozpierania, jest bardzo silny (10/10), uniemożliwia funkcjonowanie. Chory od ok. 3 lat uskarżał się na bóle głowy, ale miały one inny charakter i znacznie mniejsze natężenie. W wywiadzie nadciśnienie tętnicze. </paragraph>
            <paragraph> W badaniu CT głowy z dnia 14.02.2012: zmiana ogniskowa o wymiarach 43 x 35 mm, u podstawy prawego płata czołowego. </paragraph>
          </text>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.31"/>
          <code code="29545-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Physical findings"/>
          <title>Badanie przedmiotowe</title>
          <text>
            <paragraph> Bez objawów oponowych, dyskretny ośrodkowy niedowład n VII lewego, prawidłowe napięcie mięśniowe w kk. górnych z niewielkiego stopnia dystalnym niedowładem lewej k. górnej i asymetrią odruchów głębokich L>P, prawidłowe napięcie i siła mięśniowa kk. dolnych z asymetrią odruchów głębokich L>P, tendencja do objawu Babińskiego po stronie lewej. </paragraph>
            <paragraph>
              <caption>Ciśnienie tętnicze</caption>
               150/90 mmHg             </paragraph>
          </text>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.1"/>
          <code code="29548-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis"/>
          <title>Rozpoznania</title>
          <text>
            <table>
              <tbody>
                <tr ID="OBS_1">
                  <td>Oponiak podstawy płata czołowego</td>
                  <td>D32.0</td>
                </tr>
                <tr ID="OBS_2">
                  <td>Nadciśnienie tętnicze</td>
                  <td>I10</td>
                </tr>
              </tbody>
            </table>
          </text>
          <entry>
            <templateId root="2.16.840.1.113883.3.4424.13.10.4.1"/>
            <organizer classCode="BATTERY" moodCode="EVN">
              <code code="8319008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Principal diagnosis"/>
              <statusCode code="completed"/>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <code code="D32.0" codeSystem="2.16.840.1.113883.6.3" codeSystemName="icd10" displayName="Nowotwór niezłośliwy opon mózgowych"/>
                  <text>
                    <reference value="#OBS_1"/>
                  </text>
                </observation>
              </component>
            </organizer>
          </entry>
          <entry>
            <templateId root="2.16.840.1.113883.3.4424.13.4.2"/>
            <organizer classCode="BATTERY" moodCode="EVN">
              <code code="85097005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Secondary diagnosis"/>
              <statusCode code="completed"/>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <code code="I10" codeSystem="2.16.840.1.113883.6.3" codeSystemName="icd10" displayName="Samoistne (pierwotne) nadcisnienie"/>
                  <text>
                    <reference value="#OBS_2"/>
                  </text>
                </observation>
              </component>
            </organizer>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.32"/>
          <code code="57828-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescriptions/Prescription list"/>
          <title>Zalecenia</title>
          <text>
            <list>
              <item>Skierowanie do szpitala na oddział neurochirurgii</item>
              <item ID="SBADM_1">Dexamethason 1 mg, 3 x 2 tabl.</item>
              <item ID="SBADM_2">Ketonal 100 mg, 2 x 1 tabl. (rano i wieczorem)</item>
            </list>
          </text>
          <entry>
            <templateId root="2.16.840.1.113883.3.4424.13.10.4.22"/>
            <substanceAdministration classCode="SBADM" moodCode="RQO">
              <text>
                <reference value="#SBADM_1"/>
              </text>
              <consumable>
                <manufacturedProduct>
                  <templateId root="2.16.840.1.113883.3.4424.13.10.4.21"/>
                  <manufacturedLabeledDrug>
                    <code code="100999" codeSystem="2.16.840.1.113883.3.4424.6.1" displayName="Dexamethason 1mg tabletki"/>
                  </manufacturedLabeledDrug>
                </manufacturedProduct>
              </consumable>
            </substanceAdministration>
          </entry>
          <entry>
            <templateId root="2.16.840.1.113883.3.4424.13.10.4.22"/>
            <substanceAdministration classCode="SBADM" moodCode="RQO">
              <text>
                <reference value="#SBADM_2"/>
              </text>
              <consumable>
                <manufacturedProduct>
                  <templateId root="2.16.840.1.113883.3.4424.13.10.4.21"/>
                  <manufacturedLabeledDrug>
                    <code code="100998" codeSystem="2.16.840.1.113883.3.4424.6.1" displayName="Ketonal 100mg tabletki"/>
                  </manufacturedLabeledDrug>
                </manufacturedProduct>
              </consumable>
            </substanceAdministration>
          </entry>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>

Konsultacja neurologiczna (zawierająca treść dokumentu w formacie PDF) [Show example]

<ClinicalDocument>
  <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="2.16.840.1.113883.3.4424.13.10.1.15" extension="1.2"/>
  <id extension="2345678" root="2.16.840.1.113883.3.4424.2.7.0.7.1" displayable="false"/>
  <code code="11488-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Consult note">
    <translation code="05.00" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Konsultacja lekarska"/>
  </code>
  <title>Konsultacja neurologa</title>
  <effectiveTime value="20140906"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="pl-PL"/>
  <setId extension="432231" root="2.16.840.1.113883.3.4424.2.7.0.7.2"/>
  <versionNumber value="1"/>
  <recordTarget>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.3"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.54"/>
    <patientRole>
      <id extension="12345" root="2.16.840.1.113883.3.4424.2.7.0.17.1" displayable="false"/>
      <id extension="62091599999" 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>
        <name>
          <given>Jan</given>
          <given>Franciszek</given>
          <family>Kowalski</family>
        </name>
        <birthTime value="19620915"/>
      </patient>
      <providerOrganization classCode="ORG">
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.2"/>
        <id extension="1007" root="2.16.840.1.113883.3.4424.2.3.1" displayable="false"/>
      </providerOrganization>
    </patientRole>
  </recordTarget>
  <author>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.4"/>
    <time value="20140906"/>
    <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"/>
    <assignedCustodian>
      <representedCustodianOrganization>
        <id extension="1007" root="2.16.840.1.113883.3.4424.2.3.1" displayable="false"/>
      </representedCustodianOrganization>
    </assignedCustodian>
  </custodian>
  <legalAuthenticator>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.6"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.55"/>
    <time value="20140906"/>
    <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>
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/>
        <name>
          <prefix>dr n. med.</prefix>
          <given>Piotr</given>
          <family>Nowak</family>
        </name>
      </assignedPerson>
      <representedOrganization>
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.2"/>
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.15"/>
        <id extension="000000046985-01" root="2.16.840.1.113883.3.4424.2.4.53.1"/>
        <telecom use="PUB" value="tel:22-1111123"/>
        <telecom use="PUB" value="fax:22-1111100"/>
        <addr>
          <country>Polska</country>
          <postalCode>00-950</postalCode>
          <city>Warszawa</city>
          <streetName>Litewska</streetName>
          <houseNumber>18</houseNumber>
        </addr>
        <asOrganizationPartOf>
          <code code="L" codeSystem="2.16.840.1.113883.3.4424.11.3.19" codeSystemName="RODZ_PRAKTYKI" displayName="Praktyka lekarska"/>
          <wholeOrganization>
            <id extension="000000046985" root="2.16.840.1.113883.3.4424.2.4.53"/>
            <id extension="123456789" root="2.16.840.1.113883.3.4424.2.2.1" displayable="true"/>
            <name>Praktyka lekarska Jan Nowak</name>
          </wholeOrganization>
        </asOrganizationPartOf>
      </representedOrganization>
      <extPL:boundedBy typeCode="PART">
        <extPL:templateId root="2.16.840.1.113883.3.4424.13.10.2.44"/>
        <extPL:reimbursementRelatedContract classCode="CNTRCT" moodCode="EVN">
          <extPL:id extension="07-20048-33" root="2.16.840.1.113883.3.4424.8.6.7"/>
          <extPL:code/>
          <extPL:bounding typeCode="PART">
            <extPL:reimburser classCode="UNDWRT">
              <extPL:id extension="07" root="2.16.840.1.113883.3.4424.3.1"/>
            </extPL:reimburser>
          </extPL:bounding>
        </extPL:reimbursementRelatedContract>
      </extPL:boundedBy>
    </assignedEntity>
  </legalAuthenticator>
  <documentationOf typeCode="DOC">
    <serviceEvent classCode="ACT" moodCode="EVN">
      <templateId root="2.16.840.1.113883.3.4424.13.10.2.51"/>
      <code code="89.005" codeSystem="2.16.840.1.113883.3.4424.11.2.6" codeSystemName="ICD-9-PL" displayName="Konsultacja neurologiczna"/>
      <effectiveTime value="20140906"/>
    </serviceEvent>
  </documentationOf>
  <componentOf typeCode="COMP">
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.52"/>
    <encompassingEncounter classCode="ENC" moodCode="EVN">
      <code code="1220" codeSystem="2.16.840.1.113883.3.4424.11.2.4" displayName="Poradnia neurologiczna"/>
      <effectiveTime value="20140906"/>
    </encompassingEncounter>
  </componentOf>
  <component typeCode="COMP" contextConductionInd="true">
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.8"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.56"/>
    <structuredBody classCode="DOCBODY" moodCode="EVN">
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.55"/>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.64"/>
          <code code="11488-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Consult note"/>
          <text>
            <renderMultiMedia referencedObject="DOCUMENT_CONTENT"/>
          </text>
          <entry>
            <observationMedia ID="DOCUMENT_CONTENT" classCode="OBS" moodCode="EVN">
              <templateId root="2.16.840.1.113883.3.4424.13.10.4.49"/>
              <value mediaType="application/pdf">
                <reference value="Konsultacja_lekarska.pdf"/>
              </value>
            </observationMedia>
          </entry>
          <entry>
            <templateId root="2.16.840.1.113883.3.4424.13.10.4.1"/>
            <organizer classCode="BATTERY" moodCode="EVN">
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