Polska Implementacja Krajowa HL7 CDA (plcda-)

eZdrowie - Projekt P1

Przykłady - [1] Protokół operacyjny

Protokół operacyjny [Pobierz przykład]

<ClinicalDocument>
  <!-- Protokół operacyjny - przykład 1 -->
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  <code code="11504-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Provider-unspecified Operation note">
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  </code>
  <title>Protokół operacyjny</title>
  <effectiveTime value="20140906"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="pl-PL"/>
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  <versionNumber value="1"/>
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    <patientRole>
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      <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>
      <providerOrganization classCode="ORG">
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    <time value="20140906"/>
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        <name>
          <prefix>dr n. med.</prefix>
          <given>Piotr</given>
          <family>Nowak</family>
        </name>
      </assignedPerson>
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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>I Oddział Chirurgii</name>
        <addr>
          <postalCode>00-950</postalCode>
          <city>Warszawa</city>
          <streetName>Solec</streetName>
          <houseNumber>12</houseNumber>
        </addr>
        <standardIndustryClassCode code="4500" codeSystem="2.16.840.1.113883.3.4424.11.2.4" displayName="Oddział chirurgiczny ogólny"/>
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            <name>Wojewódzki szpital specjalistyczny</name>
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                <name>Wojewódzki Szpital Specjalistyczny</name>
              </wholeOrganization>
            </asOrganizationPartOf>
          </wholeOrganization>
        </asOrganizationPartOf>
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    </assignedEntity>
  </legalAuthenticator>
  <documentationOf typeCode="DOC">
    <serviceEvent classCode="ACT" moodCode="EVN">
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      <id extension="9/2015" root="2.16.840.1.113883.3.4424.2.7.0.13.1" displayable="true"/>
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      <effectiveTime>
        <low value="201409060900"/>
        <high value="201409061123"/>
      </effectiveTime>
      <performer typeCode="PPRF">
        <functionCode code="PRISURG" codeSystem="2.16.840.1.113883.5.88" displayName="primary surgeon"/>
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          <templateId root="2.16.840.1.113883.3.4424.13.10.2.49"/>
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            <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>
          </assignedPerson>
        </assignedEntity>
      </performer>
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        <functionCode code="ANEST" codeSystem="2.16.840.1.113883.5.88" displayName="anesthesist"/>
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            <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/>
            <name>
              <prefix>dr n. med.</prefix>
              <given>Anna</given>
              <family>Wiśniewska</family>
            </name>
          </assignedPerson>
        </assignedEntity>
      </performer>
      <performer typeCode="SPRF">
        <functionCode code="FASST" codeSystem="2.16.840.1.113883.5.88" displayName="first assistant surgeon"/>
        <assignedEntity>
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            <name>
              <prefix>dr n. med.</prefix>
              <given>Wojciech</given>
              <family>Kowalik</family>
            </name>
          </assignedPerson>
        </assignedEntity>
      </performer>
      <performer typeCode="SPRF">
        <functionCode code="SASST" codeSystem="2.16.840.1.113883.5.88" displayName="second assistant surgeon"/>
        <assignedEntity>
          <templateId root="2.16.840.1.113883.3.4424.13.10.2.49"/>
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            <name>
              <prefix>dr n. med.</prefix>
              <given>Aleksandra</given>
              <family>Dombrowska</family>
            </name>
          </assignedPerson>
        </assignedEntity>
      </performer>
      <performer typeCode="SPRF">
        <functionCode code="TASST" codeSystem="2.16.840.1.113883.5.88" displayName="third assistant"/>
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          <assignedPerson>
            <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/>
            <name>
              <prefix>dr n. med.</prefix>
              <given>Janusz</given>
              <family>Stefański</family>
            </name>
          </assignedPerson>
        </assignedEntity>
      </performer>
    </serviceEvent>
  </documentationOf>
  <componentOf typeCode="COMP">
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.52"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.66"/>
    <encompassingEncounter classCode="ENC" moodCode="EVN">
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      <code code="4500" codeSystem="2.16.840.1.113883.3.4424.11.2.4" displayName="Oddział chirurgiczny ogólny"/>
      <effectiveTime>
        <low value="20140901"/>
      </effectiveTime>
    </encompassingEncounter>
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  <component typeCode="COMP" contextConductionInd="true">
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.8"/>
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    <structuredBody classCode="DOCBODY" moodCode="EVN">
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.41"/>
          <code code="10219-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Surgical operation note preoperative diagnosis Narrative"/>
          <title>Rozpoznanie przedoperacyjne</title>
          <text>
            <paragraph> Uchyłek dwunastnicy z krwawieniem </paragraph>
          </text>
        </section>
      </component>
      <component>
        <section>
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          <code code="10223-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Surgical operation note surgical procedure Narrative"/>
          <title>Rodzaj operacji</title>
          <text>
            <paragraph> Proste wycięcie uchyłka dwunastnicy </paragraph>
            <list>
              <caption>Procedury medyczne wykonane w trakcie zabiegu</caption>
              <item ID="PROC_1">45.31 Inne miejscowe wycięcie zmiany dwunastnicy</item>
              <item ID="PROC_2">100.3 Znieczulenie zewnątrzoponowe</item>
              <item ID="PROC_3">100.0 Znieczulenie ogólne (8:55 - 11:50)</item>
              <item ID="PROC_4">54.5 Usunięcie zrostów otrzewnowych</item>
              <item>(...)</item>
            </list>
          </text>
          <entry typeCode="COMP">
            <procedure classCode="PROC" moodCode="EVN">
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              <code code="45.31" codeSystem="2.16.840.1.113883.3.4424.11.2.6" codeSystemName="ICD-9-PL" displayName="Inne miejscowe wycięcie zmiany dwunastnicy"/>
              <text>
                <reference value="#PROC_1"/>
              </text>
            </procedure>
          </entry>
          <entry typeCode="COMP">
            <procedure classCode="PROC" moodCode="EVN">
              <templateId root="2.16.840.1.113883.3.4424.13.10.4.47"/>
              <code code="100.3" codeSystem="2.16.840.1.113883.3.4424.11.2.6" codeSystemName="ICD-9-PL" displayName="Znieczulenie zewnątrzoponowe"/>
              <text>
                <reference value="#PROC_2"/>
              </text>
            </procedure>
          </entry>
          <entry typeCode="COMP">
            <procedure classCode="PROC" moodCode="EVN">
              <templateId root="2.16.840.1.113883.3.4424.13.10.4.47"/>
              <code code="100.0" codeSystem="2.16.840.1.113883.3.4424.11.2.6" codeSystemName="ICD-9-PL" displayName="Znieczulenie ogólne"/>
              <text>
                <reference value="#PROC_3"/>
              </text>
              <effectiveTime>
                <low value="201409060855"/>
                <high value="201409061150"/>
              </effectiveTime>
            </procedure>
          </entry>
          <entry typeCode="COMP">
            <procedure classCode="PROC" moodCode="EVN">
              <templateId root="2.16.840.1.113883.3.4424.13.10.4.47"/>
              <code code="54.5" codeSystem="2.16.840.1.113883.3.4424.11.2.6" codeSystemName="ICD-9-PL" displayName="Usunięcie zrostów otrzewnowych"/>
              <text>
                <reference value="#PROC_4"/>
              </text>
            </procedure>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.43"/>
          <code code="10218-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Surgical operation note postoperative diagnosis Narrative"/>
          <title>Rozpoznanie pooperacyjne</title>
          <text>
            <paragraph> Jak wyżej </paragraph>
          </text>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.44"/>
          <code code="59768-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Procedure indications [interpretation] Narrative"/>
          <title>Wskazania</title>
          <text>
            <paragraph> Pacjent lat 51 z rozpoznanym krwawieniem oraz stwierdzonym w badaniach uchyłkiem dwunastnicy. Postępowanie wymagało usunięcia uchyłka. </paragraph>
          </text>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.45"/>
          <code code="29554-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Procedure Narrative"/>
          <title>Opis operacji</title>
          <text>
            <paragraph> Cewnik zewnątrzoponowy został założony przez anestezjologa przed rozpoczęciem operacji. Pacjenta ułożono w pozycji leżącej na plecach i wprowadzono do znieczulenia ogólnego dotchawiczego. Przed operacją podano antybiotyki (profilaktyka przeciwbakteryjna). Wprowadzono cewnik Foleya oraz sondę nosowo- żołądkową. Pole operacyjne umyto i obłożono sterylnie w typowy sposób. Przed rozpoczęciem operacji potwierdzono tożsamość pacjenta, zgodność procedury, miejsca operowanego i ułożenia oraz dostępność implantów i/lub niezbędnego wyposażenia. Wykonano pionowe cięcie w linii pośrodkowej od wyrostka mieczykowatego do okolicy tuż poniżej pępka. Pogłębiono cięcie przez tkankę podskórną, uzyskując hemostazę za pomocą elektrokoagulacji. Zidentyfikowano i nacięto kresę białą, następnie otwarto jamę otrzewnej. Zrewidowano całą jamę brzuszną (...) </paragraph>
          </text>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>