Polska Implementacja Krajowa HL7 CDA (plcda-)

 eZdrowie - Projekt P1

Przykłady - [1] Konsultacja lekarska

Konsultacja neurologiczna [Pokaż przykład]

<ClinicalDocument>
  <!-- Konsultacja lekarska - przykład 1 -->
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    <translation code="05.00" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Konsultacja lekarska"/>
  </code>
  <title>Konsultacja neurologa</title>
  <effectiveTime value="20140906"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="pl-PL"/>
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      <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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        <name>
          <prefix>dr n. med.</prefix>
          <given>Piotr</given>
          <family>Nowak</family>
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          <country>Polska</country>
          <postalCode>00-950</postalCode>
          <city>Warszawa</city>
          <streetName>Litewska</streetName>
          <houseNumber>18</houseNumber>
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            <name>Praktyka lekarska Jan Nowak</name>
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      <effectiveTime value="20140906"/>
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      <code code="1220" codeSystem="2.16.840.1.113883.3.4424.11.2.4" displayName="Poradnia neurologiczna"/>
      <effectiveTime value="20140906"/>
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  <component typeCode="COMP" contextConductionInd="true">
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        <section>
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          <code code="10164-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of present illness"/>
          <title>Wywiad lekarski</title>
          <text>
            <paragraph> Przed tygodniem pacjent zgłosił się do internisty z powodu znacznego nasilenia bólów głowy w okolicy skroniowej. Ból ma charakter rozpierania, jest bardzo silny (10/10), uniemożliwia funkcjonowanie. Chory od ok. 3 lat uskarżał się na bóle głowy, ale miały one inny charakter i znacznie mniejsze natężenie. W wywiadzie nadciśnienie tętnicze. </paragraph>
            <paragraph> W badaniu CT głowy z dnia 14.02.2012: zmiana ogniskowa o wymiarach 43 x 35 mm, u podstawy prawego płata czołowego. </paragraph>
          </text>
        </section>
      </component>
      <component>
        <section>
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          <code code="29545-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Physical findings"/>
          <title>Badanie przedmiotowe</title>
          <text>
            <paragraph> Bez objawów oponowych, dyskretny ośrodkowy niedowład n VII lewego, prawidłowe napięcie mięśniowe w kk. górnych z niewielkiego stopnia dystalnym niedowładem lewej k. górnej i asymetrią odruchów głębokich L>P, prawidłowe napięcie i siła mięśniowa kk. dolnych z asymetrią odruchów głębokich L>P, tendencja do objawu Babińskiego po stronie lewej. </paragraph>
            <paragraph>
              <caption>Ciśnienie tętnicze</caption>
               150/90 mmHg             </paragraph>
          </text>
        </section>
      </component>
      <component>
        <section>
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          <title>Rozpoznania</title>
          <text>
            <table>
              <tbody>
                <tr ID="OBS_1">
                  <td>Oponiak podstawy płata czołowego</td>
                  <td>D32.0</td>
                </tr>
                <tr ID="OBS_2">
                  <td>Nadciśnienie tętnicze</td>
                  <td>I10</td>
                </tr>
              </tbody>
            </table>
          </text>
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              <statusCode code="completed"/>
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                    <reference value="#OBS_1"/>
                  </text>
                </observation>
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                    <reference value="#OBS_2"/>
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          <code code="57828-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescriptions/Prescription list"/>
          <title>Zalecenia</title>
          <text>
            <list>
              <item>Skierowanie do szpitala na oddział neurochirurgii</item>
              <item ID="SBADM_1">Dexamethason 1 mg, 3 x 2 tabl.</item>
              <item ID="SBADM_2">Ketonal 100 mg, 2 x 1 tabl. (rano i wieczorem)</item>
            </list>
          </text>
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            <templateId root="2.16.840.1.113883.3.4424.13.10.4.22"/>
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              <text>
                <reference value="#SBADM_1"/>
              </text>
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                <manufacturedProduct>
                  <templateId root="2.16.840.1.113883.3.4424.13.10.4.21"/>
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                    <code code="100999" codeSystem="2.16.840.1.113883.3.4424.6.1" displayName="Dexamethason 1mg tabletki"/>
                  </manufacturedLabeledDrug>
                </manufacturedProduct>
              </consumable>
            </substanceAdministration>
          </entry>
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            <templateId root="2.16.840.1.113883.3.4424.13.10.4.22"/>
            <substanceAdministration classCode="SBADM" moodCode="RQO">
              <text>
                <reference value="#SBADM_2"/>
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              <consumable>
                <manufacturedProduct>
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                    <code code="100998" codeSystem="2.16.840.1.113883.3.4424.6.1" displayName="Ketonal 100mg tabletki"/>
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                </manufacturedProduct>
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          </entry>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>

Konsultacja neurologiczna (zawierająca treść dokumentu w formacie PDF) [Pokaż przykład]

<ClinicalDocument>
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  </code>
  <title>Konsultacja neurologa</title>
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  <languageCode code="pl-PL"/>
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        <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"/>
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          <prefix>dr n. med.</prefix>
          <given>Piotr</given>
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            <name>Praktyka lekarska Jan Nowak</name>
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            <renderMultiMedia referencedObject="DOCUMENT_CONTENT"/>
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            <observationMedia ID="DOCUMENT_CONTENT" classCode="OBS" moodCode="EVN">
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              <value mediaType="application/pdf">
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