Polska Implementacja Krajowa HL7 CDA (plcda-)

eZdrowie - Projekt P1

Przykłady - [1] Skierowanie na badania w związku z podejrzeniem choroby zawodowej

Skierowanie na badanie w związku z podejrzeniem choroby zawodowej [Pokaż przykład]

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  <!-- Skierowanie na badanie w związku z podejrzeniem choroby zawodowej -->
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  <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 na badanie w związku z podejrzeniem choroby zawodowej</title>
  <effectiveTime value="20130412"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="pl-PL"/>
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  <versionNumber value="1"/>
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      <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>
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  <author>
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    <time value="20130412"/>
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  <custodian>
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    <signatureCode code="S"/>
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      <code code="LEK" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Lekarz"/>
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        <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/>
        <name>
          <prefix>lek.</prefix>
          <given>Piotr</given>
          <family>Nowak</family>
        </name>
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          <extPL:code code="0718" codeSystem="2.16.840.1.113883.3.4424.11.3.3" displayName="neurologia"/>
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        <extPL:qualifiedEntity classCode="QUAL">
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          <extPL:code code="0726" codeSystem="2.16.840.1.113883.3.4424.11.3.3" displayName="radiologia i diagnostyka obrazowa"/>
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        <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>
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            <name>NZOZ „POL-MED”</name>
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                <name>POL-MED Sp. z o.o.</name>
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            </asOrganizationPartOf>
          </wholeOrganization>
        </asOrganizationPartOf>
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      <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"/>
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        </extPL:reimbursementRelatedContract>
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    </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"/>
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    <structuredBody>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.23"/>
          <code code="11340-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of occupation"/>
          <title>Wywiad zawodowy</title>
          <text>
            <paragraph>
              <caption>Aktualna sytuacja zawodowa:</caption>
               pracownik             </paragraph>
            <paragraph>
              <caption>Aktualny pracodawca (dotyczy pracownika):</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>
            <table>
              <thead>
                <tr>
                  <th>Okres zatrudnienia od-do</th>
                  <th>Stanowisko pracy</th>
                  <th>Pracodawca</th>
                  <th>Charakterystyka narażenia (czynniki szkodliwe/uciążliwe)</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>01.07.2008 - 31.03.2013</td>
                  <td>operator młota pneumatycznego</td>
                  <td>Mostostal Warszawa</td>
                  <td>wibracje</td>
                </tr>
              </tbody>
            </table>
          </text>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.24"/>
          <code code="29548-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis"/>
          <text>
            <paragraph>
              <caption>Pełna nazwa choroby zawodowej, której dotyczy podejrzenie:</caption>
              <content ID="OBS_1">22.2 Zespół wibracyjny - postać kostno-stawowa</content>
            </paragraph>
          </text>
          <entry>
            <templateId root="2.16.840.1.113883.3.4424.13.10.4.12"/>
            <observation classCode="OBS" moodCode="EVN">
              <code code="22.2" codeSystem="2.16.840.1.113883.3.4424.11.1.16" displayName="Zespół wibracyjny - postać kostno-stawowa"/>
              <text>
                <reference value="#OBS_1"/>
              </text>
            </observation>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.25"/>
          <code code="10161-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of occupational exposure"/>
          <title>Czynniki narażenia zawodowego</title>
          <text>
            <paragraph>
              <caption>Czynniki narażenia zawodowego, które wskazuje się jako przyczynę choroby zawodowej</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>Okres narażenia zawodowego na czynniki, które wskazuje się jako przyczynę choroby zawodowej</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>Miejsce zatrudnienia lub wykonywania pracy, z którym wiąże się podejrzenie choroby zawodowej będące powodem zgłoszenia podejrzenia choroby zawodowej</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>Stanowisko pracy, wydział, oddział</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>Charakterystyka wykonywanej pracy (rodzaj wykonywanych czynności)</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>
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        <section>
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          <code code="57828-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescriptions"/>
          <text>
            <paragraph ID="ENC_1"> W związku z podejrzeniem choroby zawodowej proszę o przeprowadzenie badań i wydanie orzeczenia o rozpoznaniu choroby zawodowej albo o braku podstaw do jej rozpoznania. </paragraph>
          </text>
          <entry>
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            <encounter classCode="ENC" moodCode="RQO">
              <code code="1160" codeSystem="2.16.840.1.113883.3.4424.11.2.4" displayName="Poradnia medycyny pracy"/>
              <text>
                <reference value="#ENC_1"/>
              </text>
            </encounter>
          </entry>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>