Polska Implementacja Krajowa HL7 CDA (plcda-)

eZdrowie - Projekt P1

Przykłady - [1] Wpis do karty uodpornienia

Wpis do karty uodpornienia [Pokaż przykład]

<ClinicalDocument>
  <!-- Wpis do karty uodpornienia - przykład 1 -->
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    <translation code="07.61" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Wpis do karty szczepień"/>
  </code>
  <title>Wpis do karty uodpornienia</title>
  <effectiveTime value="20150907"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="pl-PL"/>
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  <versionNumber value="1"/>
  <recordTarget>
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    <patientRole>
      <id extension="12345" root="2.16.840.1.113883.3.4424.2.7.0.17.1" displayable="false"/>
      <id extension="09290111832" 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="20090901"/>
        <guardian classCode="GUARD">
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          <guardianPerson>
            <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/>
            <name>
              <given>Maria</given>
              <family>Kowalska</family>
            </name>
          </guardianPerson>
        </guardian>
      </patient>
      <providerOrganization classCode="ORG">
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    <time value="20150907"/>
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    <assignedCustodian>
      <representedCustodianOrganization>
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      </representedCustodianOrganization>
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  <legalAuthenticator>
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    <templateId root="2.16.840.1.113883.3.4424.13.10.2.55"/>
    <time value="20150907"/>
    <signatureCode code="S"/>
    <assignedEntity xsi:type="extPL:AssignedEntity">
      <id extension="7724514" root="2.16.840.1.113883.3.4424.1.6.3" displayable="true"/>
      <code code="PIEL" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Pielęgniarka"/>
      <assignedPerson>
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/>
        <name>
          <given>Anna</given>
          <family>Nowak</family>
        </name>
      </assignedPerson>
      <representedOrganization>
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.2"/>
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.18"/>
        <id extension="2004-09" root="2.16.840.1.113883.3.4424.2.3.3" displayable="true"/>
        <name>Oddział neurologii</name>
        <addr>
          <postalCode>00-950</postalCode>
          <city>Warszawa</city>
          <streetName>Solec</streetName>
          <houseNumber>12</houseNumber>
        </addr>
        <standardIndustryClassCode code="4220" codeSystem="2.16.840.1.113883.3.4424.11.2.4" displayName="Oddział neurologiczny"/>
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            <name>Wojewódzki szpital specjalistyczny</name>
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                <name>Wojewódzki szpital specjalistyczny</name>
              </wholeOrganization>
            </asOrganizationPartOf>
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        </asOrganizationPartOf>
      </representedOrganization>
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        <extPL:templateId root="2.16.840.1.113883.3.4424.13.10.2.44"/>
        <extPL:reimbursementRelatedContract moodCode="EVN" classCode="CNTRCT">
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          <extPL:bounding typeCode="PART">
            <extPL:reimburser classCode="UNDWRT">
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      </extPL:boundedBy>
    </assignedEntity>
  </legalAuthenticator>
  <documentationOf typeCode="DOC">
    <serviceEvent classCode="ACT" moodCode="EVN">
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      <code code="99.39" codeSystem="2.16.840.1.113883.3.4424.11.2.6" codeSystemName="ICD-9-PL" displayName="Podanie szczepionki di-te-per"/>
      <effectiveTime value="20150907"/>
    </serviceEvent>
  </documentationOf>
  <componentOf typeCode="COMP">
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.52"/>
    <encompassingEncounter classCode="ENC" moodCode="EVN">
      <id extension="323432" root="2.16.840.1.113883.3.4424.2.7.0.98" displayable="true"/>
      <code code="0050" codeSystem="2.16.840.1.113883.3.4424.11.2.4" displayName="Punkt szczepień"/>
      <effectiveTime value="20150907"/>
    </encompassingEncounter>
  </componentOf>
  <component typeCode="COMP" contextConductionInd="true">
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    <structuredBody classCode="DOCBODY" moodCode="EVN">
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.53"/>
          <title>Podanie szczepionki</title>
          <text>
            <table>
              <thead>
                <tr>
                  <th>Rodzaj szczepionki</th>
                  <th>Data i godzina wykonania szczepienia</th>
                  <th>Miejsce/droga podania szczepionki</th>
                  <th>Nazwa szczepionki</th>
                  <th>Nr serii szczepionki</th>
                  <th>Osoba wykonująca szczepienie</th>
                </tr>
              </thead>
              <tbody>
                <tr ID="SBADM_1">
                  <td>DTaP - 1 dawka przypominająca</td>
                  <td>2015-09-07 11:25</td>
                  <td>głęboko domięśniowo</td>
                  <td>Boostrix 0,5 ml (1 dawka) zawiesina do wstrzykiwań</td>
                  <td>123456789</td>
                  <td>Anna Nowak</td>
                </tr>
              </tbody>
            </table>
          </text>
          <entry typeCode="COMP">
            <substanceAdministration classCode="SBADM" moodCode="EVN">
              <templateId root="2.16.840.1.113883.3.4424.13.10.4.42"/>
              <code code="IMMUNIZ" codeSystem="2.16.840.1.113883.5.4" displayName="Immunization"/>
              <text>
                <reference value="#SBADM_1"/>
              </text>
              <effectiveTime value="201509071125"/>
              <routeCode code="IMD" codeSystem="2.16.840.1.113883.5.112" displayName="Injection, intramuscular, deep"/>
              <consumable>
                <manufacturedProduct>
                  <manufacturedMaterial>
                    <code code="1234" codeSystem="2.16.840.1.113883.3.4424.6.1" displayName="Boostrix 0,5 ml (1 dawka) zawiesina do wstrzykiwań"/>
                    <lotNumberText>123456789</lotNumberText>
                  </manufacturedMaterial>
                </manufacturedProduct>
              </consumable>
              <performer typeCode="PRF">
                <templateId root="2.16.840.1.113883.3.4424.13.10.4.17"/>
                <assignedEntity>
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                  <code code="PIEL" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Pielęgniarka"/>
                  <assignedPerson>
                    <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/>
                    <name>
                      <given>Anna</given>
                      <family>Nowak</family>
                    </name>
                  </assignedPerson>
                </assignedEntity>
              </performer>
            </substanceAdministration>
          </entry>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>