Polska Implementacja Krajowa HL7 CDA (plcda-)

eZdrowie - Projekt P1

Przykłady - [1] Skierowanie do zakładu opiekuńczego

Skierowanie do zakładu opiekuńczo-leczniczego [Pokaż przykład]

<ClinicalDocument>
  <!-- Skierowanie do zakładu opiekuńczo-leczniczego -->
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
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  <code code="34140-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Transfer of care referral note">
    <translation code="02.12" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Prośba o objęcie opieką"/>
  </code>
  <title>Skierowanie do zakładu opiekuńczo-leczniczego</title>
  <effectiveTime value="20130412"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="pl-PL"/>
  <setId extension="432231" root="2.16.840.1.113883.3.4424.7.4.2"/>
  <versionNumber value="1"/>
  <recordTarget>
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    <templateId root="2.16.840.1.113883.3.4424.13.10.2.26"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.36"/>
    <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>
      <telecom value="tel:33-3141123"/>
      <patient>
        <name>
          <given>Jan</given>
          <given>Franciszek</given>
          <family>Kowalski</family>
        </name>
        <birthTime value="19620915"/>
      </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"/>
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      </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="2.16.840.1.113883.3.4424.13.10.2.37"/>
    <structuredBody>
      <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>Rozpoznanie w języku polskim według ICD-10 (choroba zasadnicza i choroby współistniejące)</title>
          <text>
            <paragraph>
              <content ID="OBS_1">I25.2 Przebyty zawał mięśnia sercowego ściany przedniej</content>
              <br/>
            </paragraph>
          </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="I25.2" codeSystem="2.16.840.1.113883.6.3" codeSystemName="icd10" displayName="Stary (przebyty) zawał serca"/>
                  <text>
                    <reference value="#OBS_1"/>
                  </text>
                </observation>
              </component>
            </organizer>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.13"/>
          <code code="19009-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Medication current"/>
          <title>Dotychczasowe leczenie</title>
          <text>
             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>
              <caption>Potrzeba kontynuacji dotychczasowego leczenia:</caption>
               tak             </paragraph>
          </text>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.14"/>
          <code code="10158-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of functional status"/>
          <text>
            <paragraph>
              <caption>Liczba punktów w skali Barthel, którą uzyskał świadczeniobiorca:</caption>
               20             </paragraph>
          </text>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.15"/>
          <code code="57828-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescriptions"/>
          <text>
            <paragraph ID="ENC_1"> Kieruję pacjenta do zakładu opiekuńczo-leczniczego. </paragraph>
            <paragraph>
              <caption>Przypadek nagły, wynikający ze zdarzeń losowych i uzasadniony stanem zdrowia:</caption>
               nie             </paragraph>
          </text>
          <entry>
            <templateId root="2.16.840.1.113883.3.4424.13.10.4.9"/>
            <encounter classCode="ENC" moodCode="RQO">
              <code code="5170" codeSystem="2.16.840.1.113883.3.4424.11.2.4" displayName="Zakład/Oddział opiekuńczo-leczniczy"/>
              <text>
                <reference value="#ENC_1"/>
              </text>
              <priorityCode code="R" codeSystem="2.16.840.1.113883.5.7" displayName="routine"/>
            </encounter>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.2"/>
          <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation comment"/>
          <text>
            <paragraph>
              <caption>Lekarz POZ świadczeniobiorcy:</caption>
               Lorem ipsum dolor sit amet, consectetur adipiscing elit.             </paragraph>
            <paragraph>
              <caption>Pielęgniarka POZ świadczeniobiorcy:</caption>
               Lorem ipsum dolor sit amet, consectetur adipiscing elit.             </paragraph>
          </text>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>