Polska Implementacja Krajowa HL7 CDA (plcda-)

eZdrowie - Projekt P1

Przykłady - [1] Dokument zlecenia na zaopatrzenie w wyroby medyczne

Zlecenie jednorazowe na gorset [Pokaż przykład]

<ClinicalDocument xsi:type="extPL:ClinicalDocument">
  <!-- Zlecenie jednorazowe na gorset -->
  <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="2.16.840.1.113883.3.4424.13.10.1.5" extension="1.2"/>
  <id extension="2345678" root="2.16.840.1.113883.3.4424.7.3.1" displayable="false"/>
  <code code="57829-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for medical equipment or product Document">
    <translation code="02.81" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Zlecenie na zaopatrzenie w wyroby medyczne">
      <qualifier>
        <name code="TZLECWM" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb zlecenia na zapotrzebowanie wyrobu medycznego"/>
        <value code="JEDN" displayName="Zlecenie jednorazowe" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3"/>
      </qualifier>
    </translation>
  </code>
  <title>Zlecenie na zaopatrzenie w wyroby medyczne</title>
  <effectiveTime value="20130412"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="pl-PL"/>
  <setId extension="432231" root="2.16.840.1.113883.3.4424.7.3.2" displayable="true"/>
  <versionNumber value="1"/>
  <recordTarget>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.3"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.29"/>
    <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>
        <name>
          <given>Jan</given>
          <given>Franciszek</given>
          <family>Kowalski</family>
        </name>
        <birthTime value="19620116"/>
      </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="2.16.840.1.113883.3.4424.13.10.2.63"/>
    <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>
  <participant typeCode="IND">
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.19"/>
    <associatedEntity classCode="UNDWRT">
      <id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/>
    </associatedEntity>
  </participant>
  <component>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.8"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.30"/>
    <structuredBody>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.8"/>
          <title>Określenie wyrobu medycznego</title>
          <text ID="SPLY_1">
            <paragraph>
              <caption>Liczba porządkowa wyrobu medycznego:</caption>
               9170.06             </paragraph>
            <paragraph>
              <caption>Liczba sztuk:</caption>
               1             </paragraph>
            <paragraph>
              <caption>Określenie wyrobu medycznego wraz z pisemnym uzasadnieniem (np. według klasyfikacji ICD-10):</caption>
               Gorset lędźwiowo - krzyżowy wg Williamsa             </paragraph>
            <paragraph>
              <caption>Zaopatrzenie:</caption>
               nie dotyczy             </paragraph>
            <paragraph>
              <caption>Dodatkowe wskazania zlecającego zaopatrzenie:</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>
          <entry>
            <templateId root="2.16.840.1.113883.3.4424.13.10.4.7"/>
            <supply classCode="SPLY" moodCode="RQO">
              <text>
                <reference value="#SPLY_1"/>
              </text>
              <quantity value="1"/>
              <product>
                <manufacturedProduct>
                  <manufacturedMaterial>
                    <code code="9170.06" codeSystem="2.16.840.1.113883.3.4424.11.1.43" displayName="Gorset lędźwiowo - krzyżowy wg Williamsa"/>
                  </manufacturedMaterial>
                </manufacturedProduct>
              </product>
            </supply>
          </entry>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>

Zlecenie jednorazowe na nebulizator [Pokaż przykład]

<ClinicalDocument xsi:type="extPL:ClinicalDocument">
  <!-- Zlecenie jednorazowe na nebulizator -->
  <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="2.16.840.1.113883.3.4424.13.10.1.5" extension="1.2"/>
  <id extension="554433" root="2.16.840.1.113883.3.4424.7.3.1" displayable="false"/>
  <code code="57829-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for medical equipment or product Document">
    <translation code="02.81" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Zlecenie na zaopatrzenie w wyroby medyczne">
      <qualifier>
        <name code="TZLECWM" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb zlecenia na zapotrzebowanie wyrobu medycznego"/>
        <value code="JEDN" displayName="Zlecenie jednorazowe" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3"/>
      </qualifier>
    </translation>
  </code>
  <title>Zlecenie na zaopatrzenie w wyroby medyczne</title>
  <effectiveTime value="20130412"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="pl-PL"/>
  <setId extension="555666" root="2.16.840.1.113883.3.4424.7.3.2" displayable="true"/>
  <versionNumber value="1"/>
  <recordTarget>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.3"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.29"/>
    <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>
        <name>
          <given>Jan</given>
          <given>Franciszek</given>
          <family>Kowalski</family>
        </name>
        <birthTime value="19620116"/>
      </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="2.16.840.1.113883.3.4424.13.10.2.63"/>
    <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>
  <participant typeCode="IND">
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.19"/>
    <associatedEntity classCode="UNDWRT">
      <id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/>
    </associatedEntity>
  </participant>
  <component>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.8"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.30"/>
    <structuredBody>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.8"/>
          <title>Środek pomocniczy</title>
          <text ID="SPLY_1">
            <paragraph>
              <caption>Liczba porządkowa wyrobu medycznego:</caption>
               9254.01             </paragraph>
            <paragraph>
              <caption>Liczba sztuk:</caption>
               1             </paragraph>
            <paragraph>
              <caption>Określenie wyrobu medycznego wraz z pisemnym uzasadnieniem (np. według klasyfikacji ICD-10):</caption>
               Inhalator dyszowy - nebulizator (generator aerozolu)             </paragraph>
            <paragraph>
              <caption>Zaopatrzenie:</caption>
               nie dotyczy             </paragraph>
            <paragraph>
              <caption>Dodatkowe wskazania zlecającego zaopatrzenie:</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>
          <entry>
            <templateId root="2.16.840.1.113883.3.4424.13.10.4.7"/>
            <supply classCode="SPLY" moodCode="RQO">
              <text>
                <reference value="#SPLY_1"/>
              </text>
              <quantity value="1"/>
              <product>
                <manufacturedProduct>
                  <manufacturedMaterial>
                    <code code="9254.01" codeSystem="2.16.840.1.113883.3.4424.11.1.43" displayName="Inhalator dyszowy: - nebulizator (generator aerozolu)"/>
                  </manufacturedMaterial>
                </manufacturedProduct>
              </product>
            </supply>
          </entry>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>

Zlecenie jednorazowe na szkła optyczne [Pokaż przykład]

<ClinicalDocument xsi:type="extPL:ClinicalDocument">
  <!-- Zlecenie jednorazowe na szkła optyczne -->
  <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="2.16.840.1.113883.3.4424.13.10.1.5" extension="1.2"/>
  <id extension="9999" root="2.16.840.1.113883.3.4424.7.3.1" displayable="false"/>
  <code code="57829-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for medical equipment or product Document">
    <translation code="02.81" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Zlecenie na zaopatrzenie w wyroby medyczne">
      <qualifier>
        <name code="TZLECWM" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb zlecenia na zapotrzebowanie wyrobu medycznego"/>
        <value code="JEDN" displayName="Zlecenie jednorazowe" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3"/>
      </qualifier>
    </translation>
  </code>
  <title>Zlecenie na jednorazowe zapotrzebowanie w środki pomocnicze</title>
  <effectiveTime value="20130412"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="pl-PL"/>
  <setId extension="8790" root="2.16.840.1.113883.3.4424.7.3.2" displayable="true"/>
  <versionNumber value="1"/>
  <recordTarget>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.3"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.29"/>
    <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>
        <name>
          <given>Jan</given>
          <given>Franciszek</given>
          <family>Kowalski</family>
        </name>
        <birthTime value="19620116"/>
      </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="2.16.840.1.113883.3.4424.13.10.2.63"/>
    <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>
  <participant typeCode="IND">
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.19"/>
    <associatedEntity classCode="UNDWRT">
      <id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/>
    </associatedEntity>
  </participant>
  <component>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.8"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.30"/>
    <structuredBody>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.8"/>
          <title>Określenie wyrobu medycznego</title>
          <text ID="SPLY_1">
            <paragraph>
              <caption>Liczba porządkowa wyrobu medycznego:</caption>
               9221             </paragraph>
            <paragraph>
              <caption>Liczba sztuk:</caption>
               1             </paragraph>
            <paragraph>
              <caption>Określenie wyrobu medycznego wraz z pisemnym uzasadnieniem (np. według klasyfikacji ICD-10):</caption>
               Szkła optyczne             </paragraph>
            <table>
              <caption>Soczewki okularowe korekcyjne</caption>
              <thead>
                <tr>
                  <th/>
                  <th/>
                  <th>Sfera</th>
                  <th>Cylinder</th>
                  <th></th>
                  <th>Pryzma</th>
                  <th>Odległość źrenic</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td rowspan="2">Do dali</td>
                  <td>OP</td>
                  <td>-3.0</td>
                  <td>-2.5</td>
                  <td>20</td>
                  <td>3.0</td>
                  <td rowspan="2">68 mm</td>
                </tr>
                <tr>
                  <td>OL</td>
                  <td>-2.0</td>
                  <td>-1.5</td>
                  <td>20</td>
                  <td>3.0</td>
                </tr>
              </tbody>
            </table>
            <paragraph>
              <caption>Dodatkowe wskazania zlecającego zaopatrzenie:</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>
          <entry>
            <templateId root="2.16.840.1.113883.3.4424.13.10.4.7"/>
            <supply classCode="SPLY" moodCode="RQO">
              <text>
                <reference value="#SPLY_1"/>
              </text>
              <quantity value="1"/>
              <product>
                <manufacturedProduct>
                  <manufacturedMaterial>
                    <code code="9221" codeSystem="2.16.840.1.113883.3.4424.11.1.43" displayName="Szkła optyczne"/>
                  </manufacturedMaterial>
                </manufacturedProduct>
              </product>
            </supply>
          </entry>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>

Zlecenie powtarzalne na pieluchomajtki anatomiczne [Pokaż przykład]

<ClinicalDocument xsi:type="extPL:ClinicalDocument">
  <!-- Zlecenie powtarzalne na pieluchomajtki anatomiczne -->
  <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="2.16.840.1.113883.3.4424.13.10.1.5" extension="1.2"/>
  <id extension="4567" root="2.16.840.1.113883.3.4424.7.3.1" displayable="false"/>
  <code code="57829-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for medical equipment or product Document">
    <translation code="02.81" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Zlecenie na zaopatrzenie w wyroby medyczne">
      <qualifier>
        <name code="TZLECWM" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb zlecenia na zapotrzebowanie wyrobu medycznego"/>
        <value code="POWT" displayName="Zlecenie powtarzalne" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/>
      </qualifier>
    </translation>
  </code>
  <title>Zlecenie na comiesięczne zapotrzebowanie w środki pomocnicze</title>
  <effectiveTime value="20130412"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="pl-PL"/>
  <setId extension="3333" root="2.16.840.1.113883.3.4424.7.3.2" displayable="true"/>
  <versionNumber value="1"/>
  <recordTarget>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.3"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.29"/>
    <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>
        <name>
          <given>Jan</given>
          <given>Franciszek</given>
          <family>Kowalski</family>
        </name>
        <birthTime value="19620116"/>
      </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="2.16.840.1.113883.3.4424.13.10.2.63"/>
    <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>
  <participant typeCode="IND">
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.19"/>
    <associatedEntity classCode="UNDWRT">
      <id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/>
    </associatedEntity>
  </participant>
  <component>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.8"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.30"/>
    <structuredBody>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.8"/>
          <title>Określenie wyrobu medycznego</title>
          <text ID="SPLY_1">
            <paragraph>
              <caption>Liczba porządkowa wyrobu medycznego:</caption>
               9254.01             </paragraph>
            <paragraph>
              <caption>Liczba sztuk:</caption>
               60 na miesiąc             </paragraph>
            <paragraph>
              <caption>Określenie wyrobu medycznego wraz z pisemnym uzasadnieniem (np. według klasyfikacji ICD-10):</caption>
               Pieluchy anatomiczne do 60 szt. miesięcznie - z chorobą nowotworowa przebiegającą w postaci owrzodziałych lub krwawiących guzów krocza, okolicy krzyżowej itp.             </paragraph>
            <paragraph>
              <caption>Dodatkowe wskazania zlecającego zaopatrzenie:</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>Miesiąc, którego dotyczy zaopatrzenie comiesięczne:</caption>
               maj - czerwiec 2013             </paragraph>
          </text>
          <entry>
            <templateId root="2.16.840.1.113883.3.4424.13.10.4.7"/>
            <supply classCode="SPLY" moodCode="RQO">
              <text>
                <reference value="#SPLY_1"/>
              </text>
              <effectiveTime xsi:type="IVL_TS">
                <low value="201305"/>
                <high value="201306"/>
              </effectiveTime>
              <quantity value="120"/>
              <product>
                <manufacturedProduct>
                  <manufacturedMaterial>
                    <code code="9244.01" codeSystem="2.16.840.1.113883.3.4424.11.1.43" displayName="Pieluchy anatomiczne do 60 szt. miesięcznie - z chorobą nowotworowa przebiegającą w postaci owrzodziałych lub krwawiących guzów krocza, okolicy krzyżowej itp."/>
                  </manufacturedMaterial>
                </manufacturedProduct>
              </product>
            </supply>
          </entry>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>