Polska Implementacja Krajowa HL7 CDA (plcda-)

eZdrowie - Projekt P1

Przykłady - [1] Dokument recepty farmaceutycznej

Recepta farmaceutyczna na Captoril [Pokaż przykład]

<ClinicalDocument xsi:type="extPL:ClinicalDocument">
  <!-- Recepta farmaceutyczna na Captopril -->
  <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="2.16.840.1.113883.3.4424.13.10.1.7" extension="1.2"/>
  <id extension="2345678" root="2.16.840.1.113883.3.4424.7.2.1" displayable="true"/>
  <code code="57833-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for medication Document">
    <translation code="04.01" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Recepta">
      <qualifier>
        <name code="KDLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Kategoria dostępności leku"/>
        <value code="Rp" codeSystem="2.16.840.1.113883.3.4424.11.1.25" codeSystemName="PolskieKlasyfikatoryHL7v3"/>
      </qualifier>
      <qualifier>
        <name code="RLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Rodzaj leku"/>
        <value code="G" displayName="Lek gotowy" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3"/>
      </qualifier>
      <qualifier>
        <name code="TWREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb wystawienia recepty"/>
        <value code="F" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Farmaceutyczna"/>
      </qualifier>
      <qualifier>
        <name code="TRREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb realizacji recepty"/>
        <value code="Z" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Zwykły"/>
      </qualifier>
    </translation>
  </code>
  <title>Recepta</title>
  <effectiveTime value="20130412"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="pl-PL"/>
  <setId extension="432231" root="2.16.840.1.113883.3.4424.7.2.2"/>
  <versionNumber value="1"/>
  <recordTarget>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.3"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.23"/>
    <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>
    </patientRole>
  </recordTarget>
  <author>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.4"/>
    <time value="20130412"/>
    <assignedAuthor>
      <id extension="545632" root="2.16.840.1.113883.3.4424.1.6.1" displayable="true"/>
    </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"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.24"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.33"/>
    <time value="20130412"/>
    <signatureCode code="S"/>
    <assignedEntity>
      <id extension="545632" root="2.16.840.1.113883.3.4424.1.6.1" displayable="true"/>
      <code code="FARM" codeSystem="2.16.840.1.113883.3.4424.11.3.18" codeSystemName="ZAWODY_MED" displayName="Farmaceuta"/>
      <assignedPerson>
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/>
        <name>
          <prefix>mgr farm.</prefix>
          <given>Artur</given>
          <family>Zwoliński</family>
        </name>
      </assignedPerson>
      <representedOrganization>
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.2"/>
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.31"/>
        <id extension="123456789" root="2.16.840.1.113883.3.4424.2.2.1" displayable="true"/>
        <id extension="1007" root="2.16.840.1.113883.3.4424.2.6" displayable="true"/>
        <name>Apteka 24h</name>
        <telecom use="PUB" value="tel:22-2345123"/>
        <telecom use="PUB" value="fax:22-2345100"/>
        <addr>
          <postalCode>00-950</postalCode>
          <city>Warszawa</city>
          <streetName>Dąbrowszczaków</streetName>
          <houseNumber>34</houseNumber>
        </addr>
      </representedOrganization>
    </assignedEntity>
  </legalAuthenticator>
  <component>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.8"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.25"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.62"/>
    <structuredBody>
      <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>Powód wystawienia recepty farmaceutycznej</caption>
              Stan nagły - kryza nadciśnieniowa.             </paragraph>
          </text>
          <component>
            <section>
              <templateId root="2.16.840.1.113883.3.4424.13.10.3.3"/>
              <code code="10186-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Identifying information"/>
              <title>Dokument uprawnień</title>
              <text>
                <paragraph>Nr leg.: 234/1992</paragraph>
              </text>
            </section>
          </component>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.38"/>
          <code code="57828-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescriptions"/>
          <text ID="SBADM_1">
            <paragraph>
              <caption>Rp. (Cito)</caption>
               Captopril 25mg tabletki
              <br/>
               1 op. po 30 tabl.             </paragraph>
            <paragraph>
              <caption>Odpłatność</caption>
               100%             </paragraph>
          </text>
          <entry>
            <templateId root="2.16.840.1.113883.3.4424.13.10.4.29"/>
            <substanceAdministration classCode="SBADM" moodCode="RQO">
              <text>
                <reference value="#SBADM_1"/>
              </text>
              <consumable>
                <manufacturedProduct>
                  <manufacturedLabeledDrug>
                    <code code="4532" codeSystem="2.16.840.1.113883.3.4424.6.1" displayName="Captopril 25mg tabletki"/>
                  </manufacturedLabeledDrug>
                </manufacturedProduct>
              </consumable>
              <entryRelationship typeCode="COMP">
                <supply xsi:type="extPL:Supply" classCode="SPLY" moodCode="RQO">
                  <effectiveTime value="20130505"/>
                  <priorityCode code="UR" codeSystem="2.16.840.1.113883.5.7"/>
                  <independentInd value="false"/>
                  <quantity value="1"/>
                  <product>
                    <manufacturedProduct>
                      <manufacturedLabeledDrug>
                        <code code="5909990673391" codeSystem="1.3.160" codeSystemName="GS1" displayName="Captopril Jelfa 25mg (30 tabl.)"/>
                      </manufacturedLabeledDrug>
                    </manufacturedProduct>
                  </product>
                </supply>
              </entryRelationship>
            </substanceAdministration>
          </entry>
          <component>
            <section>
              <templateId root="2.16.840.1.113883.3.4424.13.10.3.5"/>
              <code code="69730-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Instructions"/>
              <title>DS.</title>
              <text> 1 tabl. podjęzykowo - doraźnie w razie wzwyżki ciśnienia tętniczego </text>
            </section>
          </component>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>