Polska Implementacja Krajowa HL7 CDA (plcda-)

eZdrowie - Projekt P1

Przykłady - [1] Karta odmowy przyjęcia do szpitala

Karta odmowy przyjęcia do szpitala [Pobierz przykład]

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  <!-- Karta odmowy przyjęcia do szpitala - przykład 1 -->
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  </code>
  <title>Karta odmowy przyjęcia do szpitala</title>
  <effectiveTime value="20140906"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="pl-PL"/>
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      <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>
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    <time value="20140906"/>
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    <templateId root="2.16.840.1.113883.3.4424.13.10.2.55"/>
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    <signatureCode code="S"/>
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      <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>
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/>
        <name>
          <prefix>dr n. med.</prefix>
          <given>Piotr</given>
          <family>Nowak</family>
        </name>
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        <templateId root="2.16.840.1.113883.3.4424.13.10.2.2"/>
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.18"/>
        <id extension="2004-09" root="2.16.840.1.113883.3.4424.2.3.3" displayable="true"/>
        <name>Izba przyjęć</name>
        <addr>
          <postalCode>00-950</postalCode>
          <city>Warszawa</city>
          <streetName>Solec</streetName>
          <houseNumber>12</houseNumber>
        </addr>
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            <id extension="11223344901234" root="2.16.840.1.113883.3.4424.2.2.2" displayable="true"/>
            <name>Wojewódzki szpital specjalistyczny</name>
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                <name>Wojewódzki Szpital Specjalistyczny</name>
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            </asOrganizationPartOf>
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    <templateId root="2.16.840.1.113883.3.4424.13.10.2.69"/>
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        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.1"/>
          <code code="29548-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis"/>
          <title>Rozpoznania</title>
          <text>
            <table>
              <tbody>
                <tr ID="DIAG_2">
                  <td>Nadciśnienie tętnicze</td>
                  <td>I10</td>
                </tr>
              </tbody>
            </table>
          </text>
          <entry>
            <templateId root="2.16.840.1.113883.3.4424.13.10.4.1"/>
            <organizer classCode="BATTERY" moodCode="EVN">
              <code code="8319008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Principal diagnosis"/>
              <statusCode code="completed"/>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <code code="I10" codeSystem="2.16.840.1.113883.6.3" codeSystemName="icd10" displayName="Samoistne (pierwotne) nadciśnienie"/>
                  <text>
                    <reference value="#DIAG_2"/>
                  </text>
                </observation>
              </component>
            </organizer>
          </entry>
        </section>
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      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.30"/>
          <code code="10164-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of present illness"/>
          <title>Powód zgłoszenia do izby przyjęć</title>
          <text>
            <paragraph> Pacjent zgłosił się do izby przyjęć z powodu silnego bólu głowy w okolicy skroniowej. Ból jest silny (7/10), utrudnia 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>
          </text>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.31"/>
          <code code="29545-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Physical findings"/>
          <title>Badanie lekarskie</title>
          <text>
            <paragraph> Bez objawów oponowych, prawidłowe napięcie mięśniowe w kk. górnych, prawidłowe napięcie i siła mięśniowa kk. dolnych,objaw Babińskiego ujemny. </paragraph>
            <paragraph>
              <caption>Ciśnienie tętnicze</caption>
               200/140 mmHg             </paragraph>
            <paragraph> Po godzinie od podania leku 140/90 mmHg </paragraph>
          </text>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.35"/>
          <code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Relevant diagnostic tests/laboratory data"/>
          <title>Wyniki badań dodatkowych</title>
          <text>
            <table>
              <thead>
                <tr>
                  <th>Nazwa badania</th>
                  <th>Wynik badania</th>
                  <th>Zakres referencyjny</th>
                </tr>
              </thead>
              <tbody>
                <tr ID="OBS_1">
                  <td colspan="3" styleCode="Bold">Morfologia krwi obwodowej</td>
                </tr>
                <tr ID="OBS_2">
                  <td>WBC Krwinki białe</td>
                  <td>8,3 K/µl</td>
                  <td>4,0 - 10,0</td>
                </tr>
                <tr ID="OBS_3">
                  <td>RBC Krwinki czerwone</td>
                  <td>3,35 M/µl</td>
                  <td>4,0 - 5,0</td>
                </tr>
                <tr ID="OBS_4">
                  <td>PLT Płytki krwi</td>
                  <td>331,0 K/µl</td>
                  <td>140,0 - 400,0</td>
                </tr>
                <tr ID="OBS_5">
                  <td>HGB Hemoglobina</td>
                  <td>7,8 g/dl</td>
                  <td>12,0 - 16,0</td>
                </tr>
                <tr ID="OBS_6">
                  <td>HCT Hematokryt</td>
                  <td>27,1 %</td>
                  <td>37,0 - 47,0</td>
                </tr>
                <tr ID="OBS_7">
                  <td>MCHC</td>
                  <td>28,8 g/dl</td>
                  <td>31,0 - 36,0</td>
                </tr>
                <tr ID="OBS_8">
                  <td>MCV</td>
                  <td>80,9 fl</td>
                  <td>80,0 - 96,0</td>
                </tr>
                <tr ID="OBS_9">
                  <td>MCH</td>
                  <td>23 pg</td>
                  <td>26,0 - 32,0</td>
                </tr>
              </tbody>
            </table>
          </text>
        </section>
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      <component>
        <section>
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          <code code="55753-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Treatment information"/>
          <title>Zastosowane leczenie</title>
          <text>
            <paragraph> Captopril 25mg podjęzykowo </paragraph>
          </text>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.40"/>
          <title>Powód odmowy przyjęcia</title>
          <text>
            <paragraph> Po podaniu leku normalizacja ciśnienia tętniczego i ustąpienie dolegliwości bólowych. Brak wskazań do przyjęcia do szpitala. </paragraph>
          </text>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.32"/>
          <code code="57828-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescriptions/Prescription list"/>
          <title>Zalecenia</title>
          <text>
            <list>
              <item>Kontynuacja leczenia nadciśnienia tętniczego w POZ</item>
              <item ID="SBADM_1">Ramipril 5mg 2 x 1 tabl.</item>
              <item>Regularna kontrola ciśnienia tętniczego</item>
            </list>
          </text>
          <entry>
            <templateId root="2.16.840.1.113883.3.4424.13.10.4.22"/>
            <substanceAdministration classCode="SBADM" moodCode="RQO">
              <text>
                <reference value="#SBADM_1"/>
              </text>
              <consumable>
                <manufacturedProduct>
                  <templateId root="2.16.840.1.113883.3.4424.13.10.4.21"/>
                  <manufacturedLabeledDrug>
                    <code code="100997" codeSystem="2.16.840.1.113883.3.4424.6.1" displayName="Ramipril 5 mg tabletki"/>
                  </manufacturedLabeledDrug>
                </manufacturedProduct>
              </consumable>
            </substanceAdministration>
          </entry>
        </section>
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    </structuredBody>
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</ClinicalDocument>