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<!-- Zlecenie jednorazowe na gorset -->
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<title>Zlecenie na zaopatrzenie w wyroby medyczne</title>
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<streetName>Odkryta</streetName>
<houseNumber>41</houseNumber>
<unitID>12</unitID>
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<patient>
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<given>Jan</given>
<given>Franciszek</given>
<family>Kowalski</family>
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<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>
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<title>Określenie wyrobu medycznego</title>
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<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>
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<product>
<manufacturedProduct>
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<ClinicalDocument xsi:type="extPL:ClinicalDocument">
<!-- Zlecenie jednorazowe na nebulizator -->
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<title>Zlecenie na zaopatrzenie w wyroby medyczne</title>
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<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"/>
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<given>Piotr</given>
<family>Nowak</family>
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<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>
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<title>Zlecenie na jednorazowe zapotrzebowanie w środki pomocnicze</title>
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<houseNumber>41</houseNumber>
<unitID>12</unitID>
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<patient>
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<given>Franciszek</given>
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<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>
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<name>NZOZ „POL-MED”</name>
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<name>POL-MED Sp. z o.o.</name>
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<section>
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<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>Sfera</th>
<th>Cylinder</th>
<th>Oś</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>
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<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>
<ClinicalDocument xsi:type="extPL:ClinicalDocument">
<!-- Zlecenie powtarzalne na pieluchomajtki anatomiczne -->
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<templateId root="2.16.840.1.113883.3.4424.13.10.1.5" extension="1.1.1"/>
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<code code="57829-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for medical equipment or product Document">
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<qualifier>
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<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"/>
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<languageCode code="pl-PL"/>
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<versionNumber value="1"/>
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<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"/>
<assignedAuthor>
<id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="false"/>
</assignedAuthor> </author>
<custodian>
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<templateId root="2.16.840.1.113883.3.4424.13.10.2.20"/>
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<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"/>
<signatureCode code="S"/>
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<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>
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<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"/>
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<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>
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<name>NZOZ „POL-MED”</name>
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<extPL:id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/>
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<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>
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<templateId root="2.16.840.1.113883.3.4424.13.10.4.7"/>
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<effectiveTime xsi:type="IVL_TS">
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<manufacturedProduct>
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</manufacturedMaterial> </manufacturedProduct> </product> </supply> </entry> </section> </component> </structuredBody> </component> </ClinicalDocument>