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ref Szablon  [2] Treść historii zdrowia i choroby

ID 2.16.840.1.113883.3.4424.13.10.2.95 Data obowiązywania obowiązuje od 2020‑07‑24
Status review In Review Etykieta wersji 1.3.2.1
Nazwa plCdaOutpatientEpisodeSummaryComponent Nazwa wyświetlana [2] Treść historii zdrowia i choroby
Opis Szablon CDA dla treści historii zdrowia i choroby
Kontekst Węzły nadrzędne elementu szablonu o id 2.16.840.1.113883.3.4424.13.10.2.95
Typ CDA Header Level Template
Otwarty/Zamknięty Otwarty (pozostałe elementy poza zdefiniowanymi są dozwolone)
Używane przez / Używa
Używane przez Transakcje 0 i szablon 1, Używa 5 szablonów
Używane przez jako Nazwa Wersja
2.16.840.1.113883.3.4424.13.10.1.31 Zawierać review [1] Historia zdrowia i choroby (1.3.2.1) 2020‑07‑24
Używa jako Nazwa Wersja
2.16.840.1.113883.3.4424.13.10.3.66 Ograniczanie active [3] Sekcja postaci binarnej dokumentu karty informacyjnej leczenia szpitalnego (1.3) DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.3.94 Ograniczanie review [3] Sekcja ogólnego stanu zdrowia w historii zdrowia i choroby (1.3.2.1) DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.3.69 Ograniczanie active [3] Sekcja danych ubezpieczeniowych (1.3) DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.3.95 Ograniczanie review [3] Sekcja porady ambulatoryjnej/wizyty domowej w historii zdrowia i choroby (1.3.2.1) DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.3.96 Ograniczanie review [3] Sekcja wizyty pielęgniarskiej/położniczej w historii zdrowia i choroby (1.3.2.1) DYNAMICZNE
Relacje Specialization: szablon 2.16.840.1.113883.3.4424.13.10.2.8 (2017‑01‑02)
Przykład
Przykład
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  <templateId root="2.16.840.1.113883.3.4424.13.10.2.95"/>  <structuredBody classCode="DOCBODY" moodCode="EVN">
    <component>
      <section>
        <templateId root="2.16.840.1.113883.3.4424.13.10.3.94"/>        <code code="11322-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of General health Narrative"/>        <title>Ogólny stan zdrowia</title>        <component>
          <section>
            <templateId root="2.16.840.1.113883.3.4424.13.10.3.97"/>            <code code="29546-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of disorders Narrative"/>            <title>Choroby przewlekłe</title>            <text>
              <list>
                <item ID="DIAG_1">I10 - Nadciśnienie tętnicze</item>                <item ID="DIAG_2">E78.1 - Hipertrójglicerydemia.</item>              </list>            </text>            <author>
              <templateId root="2.16.840.1.113883.3.4424.13.10.4.90"/>              <functionCode code="LEK" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Lekarz"/>              <time value="20200702"/>              <assignedAuthor>
                <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="false"/>                <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>                </assignedPerson>              </assignedAuthor>            </author>            <entry>
              <templateId root="2.16.840.1.113883.3.4424.13.10.4.2"/>              <organizer classCode="BATTERY" moodCode="EVN">
                <code code="85097005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Secondary 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_1"/>                    </text>                  </observation>                </component>                <component>
                  <observation classCode="OBS" moodCode="EVN">
                    <code code="E78.1" codeSystem="2.16.840.1.113883.6.3" codeSystemName="icd10" displayName="Hipertrójglicerydemia"/>                    <text>
                      <reference value="#DIAG_2"/>                    </text>                  </observation>                </component>              </organizer>            </entry>          </section>        </component>        <component>
          <section>
            <templateId root="2.16.840.1.113883.3.4424.13.10.3.98"/>            <code code="11348-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Past illness Narrative"/>            <title>Przebyte choroby</title>            <text>
              <paragraph>
Przebyty epizod zatorowości płucnej w marcu 2018 roku. Przewlekła terapia przecikrzepliwa rywaroksabanem (Xarelto).
</paragraph>              <paragraph>
Przebyta borelioza skórna w kwietniu 2019 roku - leczona doksycykliną w dawce 2x100mg przez 3 tygodnie.
</paragraph>            </text>            <author>
              <templateId root="2.16.840.1.113883.3.4424.13.10.4.90"/>              <functionCode code="LEK" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Lekarz"/>              <time value="20200702"/>              <assignedAuthor>
                <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="false"/>                <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>                </assignedPerson>              </assignedAuthor>            </author>          </section>        </component>        <component>
          <section>
            <templateId root="2.16.840.1.113883.3.4424.13.10.3.99"/>            <code code="11336-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Hospitalization Narrative"/>            <title>Pobyty w szpitalu</title>            <text>
              <list>
                <caption>Pobyty na oddziałach:</caption>                <item ID="ENC_1">02.09.2019 - 10.09.2019 Oddział kardiologii</item>                <item ID="ENC_2">01.06.2020 - 06.06.2015 Oddział neurologii</item>              </list>            </text>            <author>
              <templateId root="2.16.840.1.113883.3.4424.13.10.4.90"/>              <functionCode code="LEK" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Lekarz"/>              <time value="20200702"/>              <assignedAuthor>
                <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="false"/>                <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>                </assignedPerson>              </assignedAuthor>            </author>            <entry>
              <encounter classCode="ENC" moodCode="EVN">
                <templateId root="2.16.840.1.113883.3.4424.13.10.4.50"/>                <code code="4100" codeSystem="2.16.840.1.113883.3.4424.11.2.4" displayName="Oddział kardiologiczny"/>                <text>
                  <reference value="#ENC_1"/>                </text>                <effectiveTime>
                  <low value="20190902"/>                  <high value="20190910"/>                </effectiveTime>              </encounter>            </entry>            <entry>
              <encounter classCode="ENC" moodCode="EVN">
                <templateId root="2.16.840.1.113883.3.4424.13.10.4.50"/>                <code code="4220" codeSystem="2.16.840.1.113883.3.4424.11.2.4" displayName="Oddział neurologiczny"/>                <text>
                  <reference value="#ENC_2"/>                </text>                <effectiveTime>
                  <low value="20200601"/>                  <high value="20200606"/>                </effectiveTime>              </encounter>            </entry>          </section>        </component>        <component>
          <section>
            <templateId root="2.16.840.1.113883.3.4424.13.10.3.100"/>            <code code="10167-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Surgical procedures Narrative"/>            <title>Przebyte zabiegi lub operacje</title>            <text>
              <paragraph>
Stan po cholecystektomii w 2012 roku.
</paragraph>              <paragraph>
Stan po obustronne operacji zaćmy (operacja lewego oka w 2016 roku i prawego oka w 2017 roku).
</paragraph>              <paragraph>
Stan po appendektomii przed laty.
</paragraph>            </text>            <author>
              <templateId root="2.16.840.1.113883.3.4424.13.10.4.90"/>              <functionCode code="LEK" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Lekarz"/>              <time value="20200702"/>              <assignedAuthor>
                <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="false"/>                <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>                </assignedPerson>              </assignedAuthor>            </author>          </section>        </component>        <component>
          <section>
            <templateId root="2.16.840.1.113883.3.4424.13.10.3.101"/>            <code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Immunization Narrative"/>            <title>Szczepienia i stosowane surowice</title>            <text>
              <paragraph>
Ze względu na zatrudnienie przy produkcji żywności, w 2010 roku pacjent był szczepiony przeciwko
wirusowemu zapaleniu wątroby typu A (WZW A). Otrzymał 2 dawki preparatu Avaxim w ostępie 6-ciu miesięcy.
</paragraph>              <paragraph>
W latach 2018-2019 pacjent był szczepiony przeciwko grypie przy użyciu szczepionki czteroskładnikowej.
</paragraph>            </text>            <author>
              <templateId root="2.16.840.1.113883.3.4424.13.10.4.90"/>              <functionCode code="LEK" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Lekarz"/>              <time value="20200702"/>              <assignedAuthor>
                <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="false"/>                <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>                </assignedPerson>              </assignedAuthor>            </author>          </section>        </component>        <component>
          <section>
            <templateId root="2.16.840.1.113883.3.4424.13.10.3.102"/>            <code code="10155-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of allergies, reported"/>            <title>Uczulenia</title>            <text>
              <paragraph>
Uczulenie na metamizol (Pyralgin).
</paragraph>            </text>            <author>
              <templateId root="2.16.840.1.113883.3.4424.13.10.4.90"/>              <functionCode code="LEK" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Lekarz"/>              <time value="20200702"/>              <assignedAuthor>
                <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="false"/>                <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>                </assignedPerson>              </assignedAuthor>            </author>          </section>        </component>        <component>
          <section>
            <templateId root="2.16.840.1.113883.3.4424.13.10.3.103"/>            <code code="10157-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of family member diseases Narrative"/>            <title>Wywiad rodzinny</title>            <text>
              <paragraph>
Matka pacjenta zmarła z powodu nowotworu złośliwego jelita grubego.
</paragraph>              <paragraph>
Ojciec pacjenta zmarł z powodu udaru krwotocznego móżgu.
</paragraph>              <paragraph>
Siostra pacjenta choruję na cukrzycę typu 2.
</paragraph>            </text>            <author>
              <templateId root="2.16.840.1.113883.3.4424.13.10.4.90"/>              <functionCode code="LEK" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Lekarz"/>              <time value="20200702"/>              <assignedAuthor>
                <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="false"/>                <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>                </assignedPerson>              </assignedAuthor>            </author>          </section>        </component>        <component>
          <section>
            <templateId root="2.16.840.1.113883.3.4424.13.10.3.104"/>            <code code="10158-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Functional status Narrative"/>            <title>Orzeczenia o niepełnosprawności</title>            <text>
              <paragraph>
Pacjent nie posiada orzeczeń o niepełnosprawności lub określonego stopnia niepełnosprawności.
</paragraph>            </text>            <author>
              <templateId root="2.16.840.1.113883.3.4424.13.10.4.90"/>              <functionCode code="LEK" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Lekarz"/>              <time value="20200702"/>              <assignedAuthor>
                <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="false"/>                <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>                </assignedPerson>              </assignedAuthor>            </author>          </section>        </component>      </section>    </component>    <component>
      <section>
        <templateId root="2.16.840.1.113883.10.20.1.9"/>        <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7"/>        <templateId root="2.16.840.1.113883.3.4424.13.10.3.69"/>        <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Payment sources Document"/>        <title>Dane o ubezpieczeniu i uprawnieniach</title>        <text>
          <paragraph ID="ACT_3">
            <caption>Oddział NFZ</caption>            <content styleCode="Bold">07</content>          </paragraph>          <paragraph ID="ACT_4">
            <caption>Uprawnienia dodatkowe</caption>            <content styleCode="Bold">IB</content>            ,             <content ID="EXT_DOC_1">Nr leg.: 234/1992</content>          </paragraph>        </text>        <author>
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            <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="false"/>            <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>            </assignedPerson>          </assignedAuthor>        </author>        <entry>
          <act classCode="ACT" moodCode="DEF">
            <templateId root="2.16.840.1.113883.10.20.1.20"/>            <templateId root="2.16.840.1.113883.3.4424.13.10.4.51"/>            <id nullFlavor="NA"/>            <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" displayName="Payment source"/>            <text>
              <reference value="#ACT_3"/>            </text>            <statusCode code="completed"/>            <entryRelationship typeCode="COMP">
              <act classCode="ACT" moodCode="EVN">
                <templateId root="2.16.840.1.113883.10.20.1.26"/>                <templateId root="2.16.840.1.113883.3.4424.13.10.4.61"/>                <id nullFlavor="NA"/>                <code code="PUBLICPOL" codeSystem="2.16.840.1.113883.5.4">
                  <qualifier>
                    <name code="RLUD" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Refundacja leków wynikająca z uprawnień dodatkowych"/>                    <value code="IB" displayName="IB" codeSystem="2.16.840.1.113883.3.4424.11.3.1"/>                  </qualifier>                </code>                <text>
                  <reference value="#ACT_4"/>                </text>                <statusCode code="completed"/>                <performer typeCode="PRF">
                  <assignedEntity>
                    <id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/>                  </assignedEntity>                </performer>                <reference typeCode="REFR">
                  <externalDocument classCode="DOC" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.3.4424.13.10.4.59"/>                    <text>
                      <reference value="#EXT_DOC_1"/>                    </text>                  </externalDocument>                </reference>              </act>            </entryRelationship>          </act>        </entry>      </section>    </component>    <component>
      <section>
        <templateId root="2.16.840.1.113883.3.4424.13.10.3.95"/>        <code code="11488-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Consult note"/>        <title>Porada ambulatoryjna z dnia 02.07.2020</title>        <component>
          <section>
            <templateId root="2.16.840.1.113883.3.4424.13.10.3.80"/>            <code code="10164-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Present illness Narrative"/>            <title>Badanie podmiotowe</title>            <text>
              <paragraph>
Pacjent zgłosił się z powodu występowania od około 2-ch tygodni zawrotów głowy, bez nudności i wymiotów z towarzyszącymi
zwyżkami ciśnienia tętniczego do wartości 220/110 mmHg. Zawroty głowy o typie niestabilności podłoża. Nie nasilają się
przy zmianie pozycji ciała.
</paragraph>              <paragraph>
Podoby epizod zawrotów głowy wystąpił około 6 miesięcy temu. Objawy były wówczas mniej nasilone i ustąpiły po 3-ch dniach.
</paragraph>              <paragraph>
Od 3-ch miesięcy pacjent obserwuje tendencję do wyższych wartości ciśnienia tętniczego i dużo częściej nież poprzednio podczas
domowych pomiarów 3x/dobę występują wartości ciśnienia przekraczające 140/90 mmHg.
</paragraph>            </text>            <author>
              <templateId root="2.16.840.1.113883.3.4424.13.10.4.90"/>              <functionCode code="LEK" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Lekarz"/>              <time value="20200702"/>              <assignedAuthor>
                <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="false"/>                <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>                </assignedPerson>              </assignedAuthor>            </author>          </section>        </component>        <component>
          <section>
            <templateId root="2.16.840.1.113883.3.4424.13.10.3.81"/>            <code code="22029-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Physical exam Narrative"/>            <title>Badanie przedmiotowe</title>            <text>
              <paragraph>
                <caption>Badanie ogólne</caption>                
Nad polami płucnymi szmer pęcherzykowy, symetryczny, prawidłowy. Rytm serca miarowy, HR-70/min, RR-150/90 mmHg.
Brzuch miękki, niebolesny przy palpacji, bez oporów paotlogicznych, perystaltyka słyszalna.
Bez obrzęków w kk. dolnych.
              </paragraph>              <paragraph>
                <caption>Badanie neurologiczne</caption>                
Chory przytomny, GCS 15 pkt., zachowany pełny kontakt słowno-logiczny, bez objawów oponowych, bez odchyleń
w zakresie nerwów czaszkowych, prawidłowe napięcie i siła mięśniowa kk. górnych i dolnych, bez asymetrii odruchów
głębokich, bez objawów patologicznych, bez zaburzeń czucia powierzchownego i głebokiego, niewielkie drżenie zamiarowe
w kk. górnych, chód nieco chwiejny, nie na poszerzonej podstawie, próba Romberga chwiejna.
              </paragraph>            </text>            <author>
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              <list>
                <item ID="DIAG_3">R42 - Zawroty głowy</item>                <item ID="DIAG_4">I10 - Nadciśnienie tętnicze</item>                <item ID="DIAG_5">E78.1 - Hipertrójglicerydemia.</item>              </list>            </text>            <author>
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                <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="I63.3" codeSystem="2.16.840.1.113883.6.3" codeSystemName="icd10" displayName="Zawał mózgu wywołany przez zakrzep tętnic mózgowych"/>                    <text>
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                    <code code="I10" codeSystem="2.16.840.1.113883.6.3" codeSystemName="icd10" displayName="Samoistne (pierwotne) nadciśnienie"/>                    <text>
                      <reference value="#DIAG_4"/>                    </text>                  </observation>                </component>                <component>
                  <observation classCode="OBS" moodCode="EVN">
                    <code code="E78.1" codeSystem="2.16.840.1.113883.6.3" codeSystemName="icd10" displayName="Hipertrójglicerydemia"/>                    <text>
                      <reference value="#DIAG_5"/>                    </text>                  </observation>                </component>              </organizer>            </entry>          </section>        </component>        <component>
          <section>
            <templateId root="2.16.840.1.113883.3.4424.13.10.3.92"/>            <code code="57828-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescriptions/Prescription list"/>            <title>Zalecenia</title>            <text>
              <list>
                <item>Wykonanie badania 24-godzinnego monitorowania ciśnienia tętniczego metodą Holtera.</item>                <item>Wykonanie badania USG Doppler tt. domózgowych.</item>              </list>              <list>
                <caption>Włączenie do leczenia na okres 2-ch miesięcy</caption>                <item>Betaserc 24mg - 2x1 tabl. rano i wieczorem</item>                <item>Memotropil 1200mg - 2x1 tabl. rano i w południe</item>              </list>              <list>
                <caption>Modyfikacja dotychczasowego leczenia</caption>                <item>Polocard 75 mg - 1 x 1 tabl. wieczorem</item>                <item>Tritace 10 mg - 1 x 1 tabl. rano</item>                <item>Diuver 10mg - 1x1 tabl. rano </item>                <item>Amlozek 10mg - 1x1 tabl. wieczorem</item>                <item>Kalipoz - 1x1 tabl. rano</item>              </list>            </text>            <author>
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              <list>
                <item ID="EXT_DOC_2">Skierowanie na badanie Holter RR z dnia 02.07.2020</item>                <item ID="EXT_DOC_3">Skierowanie na badanie USG Doppler tt. szyjnych i kręgowych z dnia 02.07.2020</item>              </list>            </text>            <author>
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                      <reference value="#EXT_DOC_3"/>                    </text>                  </externalDocument>                </reference>              </act>            </entry>          </section>        </component>      </section>    </component>    <component>
      <section>
        <templateId root="2.16.840.1.113883.3.4424.13.10.3.96"/>        <code code="84241-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Nurse Consult note"/>        <title>Wizyta pielęgniarska z dnia 04.07.2020</title>        <component>
          <section>
            <templateId root="2.16.840.1.113883.3.4424.13.10.3.105"/>            <code code="29545-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Physical findings Narrative"/>            <title>Opis wizyty</title>            <text>
              <paragraph>
Pacjent w stanie ogólnym dobrym. Nie zgłasza dolegliwości. Pacjent samodzielny, chodzący.
</paragraph>              <paragraph>
Parametry życiowe źyciowe w normie - HR-70/min, RR-140/90 mmHg.
</paragraph>              <paragraph>
Zgodnie z zaleceniem lekarskim wykonania badania Holter RR, pacjentowi założono aparat do 24-godzinnego
monitorowania ciśnienia tętniczego.
</paragraph>            </text>            <author>
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                  <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/>                  <name>
                    <given>Anna</given>                    <family>Wyszyńska</family>                  </name>                </assignedPerson>              </assignedAuthor>            </author>          </section>        </component>        <component>
          <section>
            <templateId root="2.16.840.1.113883.3.4424.13.10.3.106"/>            <code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social history Narrative"/>            <title>Wywiad rodzinny i warunki życia</title>            <text>
              <paragraph>
Warunki życia dobre.
</paragraph>              <paragraph>
Pajent mieszka z żoną i córką.
</paragraph>            </text>            <author>
              <templateId root="2.16.840.1.113883.3.4424.13.10.4.90"/>              <functionCode code="PIEL" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Pielęgniarka"/>              <time value="20200704"/>              <assignedAuthor>
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                  <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/>                  <name>
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@typeCode
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  Komunikat Jeżeli w dokumencie znajduje się sekcja postaci binarnej dokumentu, to nie może występować sekcja innego typu.  
hl7:structuredBody
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