Polska Implementacja Krajowa HL7 CDA (plcda-)

eZdrowie - Projekt P1

Przykłady - [1] Zalecenia pielęgniarskie przy wypisie ze szpitala

Zalecenie pielęgniarskie przy wypisie ze szpitala [Pobierz przykład]

<ClinicalDocument>
  <!-- Zalecenie pielęgniarskie przy wypisie ze szpitala - przykład 1 -->
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root="2.16.840.1.113883.3.4424.13.10.1.1"/>
  <templateId root="2.16.840.1.113883.3.4424.13.10.1.24" extension="1.1"/>
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  <code code="64295-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Nursing care plan">
    <translation code="05.50" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Zalecenia pielęgniarskie"/>
  </code>
  <title>Zalecenia pielęgniarskie przy wypisie ze szpitala</title>
  <effectiveTime value="20150907"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="pl-PL"/>
  <setId extension="432231" root="2.16.840.1.113883.3.4424.2.7.0.7.2"/>
  <versionNumber value="1"/>
  <recordTarget>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.3"/>
    <patientRole>
      <id extension="12345" root="2.16.840.1.113883.3.4424.2.7.0.17.1" displayable="false"/>
      <id extension="64012608919" 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="19640126"/>
      </patient>
      <providerOrganization classCode="ORG">
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.2"/>
        <id extension="1007" root="2.16.840.1.113883.3.4424.2.3.1" displayable="false"/>
      </providerOrganization>
    </patientRole>
  </recordTarget>
  <author>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.4"/>
    <time value="20150907"/>
    <assignedAuthor>
      <id extension="7724514" root="2.16.840.1.113883.3.4424.1.6.3" displayable="false"/>
    </assignedAuthor>
  </author>
  <custodian>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.5"/>
    <assignedCustodian>
      <representedCustodianOrganization>
        <id extension="1007" root="2.16.840.1.113883.3.4424.2.3.1" displayable="false"/>
      </representedCustodianOrganization>
    </assignedCustodian>
  </custodian>
  <legalAuthenticator>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.6"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.55"/>
    <time value="20150907"/>
    <signatureCode code="S"/>
    <assignedEntity xsi:type="extPL:AssignedEntity">
      <id extension="7724514" root="2.16.840.1.113883.3.4424.1.6.3" displayable="true"/>
      <code code="PIEL" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Pielęgniarka"/>
      <assignedPerson>
        <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/>
        <name>
          <given>Anna</given>
          <family>Nowak</family>
        </name>
      </assignedPerson>
      <representedOrganization>
        <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>Oddział neurologii</name>
        <addr>
          <postalCode>00-950</postalCode>
          <city>Warszawa</city>
          <streetName>Solec</streetName>
          <houseNumber>12</houseNumber>
        </addr>
        <standardIndustryClassCode code="4220" codeSystem="2.16.840.1.113883.3.4424.11.2.4" displayName="Oddział neurologiczny"/>
        <asOrganizationPartOf>
          <wholeOrganization>
            <templateId root="2.16.840.1.113883.3.4424.13.10.2.2"/>
            <templateId root="2.16.840.1.113883.3.4424.13.10.2.16"/>
            <id extension="11223344901234" root="2.16.840.1.113883.3.4424.2.2.2" displayable="true"/>
            <name>Wojewódzki szpital specjalistyczny</name>
            <asOrganizationPartOf>
              <wholeOrganization>
                <templateId root="2.16.840.1.113883.3.4424.13.10.2.2"/>
                <templateId root="2.16.840.1.113883.3.4424.13.10.2.14"/>
                <id extension="2004" root="2.16.840.1.113883.3.4424.2.3.1" displayable="true"/>
                <id extension="121212445" root="2.16.840.1.113883.3.4424.2.2.1" displayable="true"/>
                <name>Wojewódzki szpital specjalistyczny</name>
              </wholeOrganization>
            </asOrganizationPartOf>
          </wholeOrganization>
        </asOrganizationPartOf>
      </representedOrganization>
    </assignedEntity>
  </legalAuthenticator>
  <componentOf typeCode="COMP">
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.52"/>
    <encompassingEncounter classCode="ENC" moodCode="EVN">
      <id extension="323432" root="2.16.840.1.113883.3.4424.2.7.0.98" displayable="false"/>
      <code code="4220" codeSystem="2.16.840.1.113883.3.4424.11.2.4" displayName="Oddział neurologiczny"/>
      <effectiveTime>
        <low value="20150907"/>
        <high value="20150914"/>
      </effectiveTime>
      <location typeCode="LOC">
        <healthCareFacility classCode="SDLOC">
          <location>
            <templateId root="2.16.840.1.113883.3.4424.13.10.2.75"/>
            <name>Szpital Specjalistyczny im. Świętej Rodziny SP ZOZ, II Oddział Neurologii, sala 2</name>
          </location>
        </healthCareFacility>
      </location>
    </encompassingEncounter>
  </componentOf>
  <component typeCode="COMP" contextConductionInd="true">
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.8"/>
    <templateId root="2.16.840.1.113883.3.4424.13.10.2.73"/>
    <structuredBody classCode="DOCBODY" moodCode="EVN">
      <component>
        <section>
          <templateId root="2.16.840.1.113883.3.4424.13.10.3.50"/>
          <code code="19009-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Medication current"/>
          <text>
            <paragraph styleCode="Bold">OCENA SAMOOPIEKI W DNIU WYPISU:</paragraph>
            <paragraph>Wymagana pomoc</paragraph>
            <paragraph>
              <caption>Toaleta ciała (mycie, czesanie, golenie):</caption>
               Nie             </paragraph>
            <paragraph>
              <caption>Zmiana bielizny (rozbieranie, ubieranie):</caption>
               Nie             </paragraph>
            <paragraph>
              <caption>Odżywianie:</caption>
               Nie             </paragraph>
            <paragraph>
              <caption>Wydalanie:</caption>
               Nie             </paragraph>
            <paragraph>
              <caption>Sprawność ruchowa:</caption>
               Tak             </paragraph>
            <paragraph>
              <caption>Samodzielność w życiu codziennym:</caption>
               Nie             </paragraph>
            <paragraph styleCode="Bold">ZALECENIA PIELĘGNIARSKIE:</paragraph>
            <paragraph>Postępowanie z miejscem po wkłuciu dożylnym: okłady hirudynowo-alkoholowe</paragraph>
            <paragraph styleCode="Bold">WSKAZÓWKI DLA PACJENTA:</paragraph>
            <paragraph>systematyczne przyjmowanie leków zleconych przez lekarza</paragraph>
            <paragraph>zakaz przyjmowania leków nie zleconych przez lekarza </paragraph>
            <paragraph>zakaz picia alkoholu i środków pochodnych</paragraph>
            <paragraph>kontynuacja programu terapeutycznego</paragraph>
          </text>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>