Polska Implementacja Krajowa HL7 CDA (plcda-)

 eZdrowie - Projekt P1

Przykłady - [1] Skierowanie do szpitala psychiatrycznego

Skierowanie do szpitala psychiatrycznego [Pokaż przykład]

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  <title>Skierowanie do szpitala psychiatrycznego</title>
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          <given>Jan</given>
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          <postalCode>00-950</postalCode>
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          <code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social history"/>
          <text>
            <paragraph>
              <caption>Zamieszkuje:</caption>
               wspólnie z innymi osobami             </paragraph>
            <paragraph>
              <caption>Stan cywilny:</caption>
               żonaty             </paragraph>
            <paragraph>
              <caption>Zatrudnienie:</caption>
               na utrzymaniu innych osób             </paragraph>
            <paragraph>
              <caption>Wykształcenie:</caption>
               wyższe             </paragraph>
            <paragraph> Osoba badana jest ubezwłasnowolniona całkowicie. </paragraph>
          </text>
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            <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>Dane o osobach będzących z mocy prawa uczestnikami postępowania sądowego (art. 46 ust. 1 ustawy z dnia 19.08.1994 o ochronie zdrowia psychicznego):</title>
              <text>
                <paragraph>
                  <caption>małżonek:</caption>
                   Joanna Kowalska, Odkryta 41 m. 12, Warszawa                 </paragraph>
              </text>
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              <caption>Wywiad od osoby badanej:</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>Wywiad od rodziny i innych osób:</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>
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              <caption>Ocena stanu fizycznego:</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>Ocena stanu psychicznego:</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>
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            <paragraph>
              <caption>Rozpoznanie wstępne:</caption>
               Jakościowe zaburzenia świadomości. Urojenia prześladowania.             </paragraph>
          </text>
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          <text>
            <paragraph ID="ENC_1"> Kieruję pacjenta do szpitala psychiatrycznego. </paragraph>
          </text>
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                <reference value="#ENC_1"/>
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            <paragraph>
              <caption>Stwierdzam, że:</caption>
               nieprzyjęcie osoby badanej do szpitala psychiatrycznego spowoduje pogorszenie stanu zdrowia psychicznego.             </paragraph>
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