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# Szablon [1] Skierowanie

ID | 2.16.840.1.113883.3.4424.13.10.1.4 | Data obowiązywania | obowiązuje od 2020‑06‑08
Status | Active | Etykieta wersji | 1.3.2
Nazwa | plCdaReferral | Nazwa wyświetlana | [1] Skierowanie
Opis | Szablon CDA dokumentu skierowania
Kontekst | Nazwa ścieżki /
Typ | CDA Document Level Template
Otwarty/Zamknięty | Otwarty (pozostałe elementy poza zdefiniowanymi są dozwolone)
Używane przez / Używa |
Używane przez Szablony 1 transakcji i 0, Używa 10 szablonów
Używane przez | jako | Nazwa | Wersja
--- | --- | --- | ---
plcda-transaction-2 | Transakcja | Dokument skierowania | 2014‑08‑14
Używa | jako | Nazwa | Wersja
2.16.840.1.113883.3.4424.13.10.2.26 | Zawierać | [2] Dane pacjenta dla dokumentu skierowania (1.3.2) | DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.2.86 | Zawierać | [2] Autor dokumentu skierowania (1.3) | DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.2.90 | Zawierać | [2] Dane asystenta medycznego (1.3.1.2) | DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.2.20 | Zawierać | [2] Organizacja odpowiedzialna za dokument dla P1 (1.3) | DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.2.61 | Zawierać | [2] Odbiorca informacji (bazowy) (1.3.1) | DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.2.6 | Zawierać | [2] Wystawca dokumentu (bazowy) (1.3.2) | DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.2.19 | Zawierać | [2] Dane ubezpieczyciela publicznego (bazowy) (1.3) | DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.2.53 | Zawierać | [2] Dane zlecenia (bazowy) (1.3) | DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.2.21 | Zawierać | [2] Dokument powiązany dla P1 (1.3) | DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.2.28 | Zawierać | [2] Treść dokumentu skierowania (1.3) | DYNAMICZNE
Relacje | Specialization: szablon 2.16.840.1.113883.3.4424.13.10.1.2 (2014‑09‑23)
Przykład |
Przykład
`<ClinicalDocument xsi:type="extPL:ClinicalDocument"> <!-- Skierowanie na kardiologię --> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root="2.16.840.1.113883.3.4424.13.10.1.4" extension="1.3.2"/> <id extension="2345678" root="2.16.840.1.113883.3.4424.7.4.1" displayable="false"/> <code code="57832-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for diagnostic or specialist care Document"> <translation code="02.10" displayName="Skierowanie na badanie lub leczenie" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1"/> </code> <title>Skierowanie do szpitala</title> <effectiveTime value="20141020"/> <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/> <languageCode code="pl-PL"/> <setId extension="432231" root="2.16.840.1.113883.3.4424.7.4.2"/> <versionNumber value="1"/> <recordTarget> <templateId root="2.16.840.1.113883.3.4424.13.10.2.26"/> <patientRole> <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> </patientRole> </recordTarget> <author> <templateId root="2.16.840.1.113883.3.4424.13.10.2.86"/> <functionCode code="LEK" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Lekarz"/> <time value="20130412"/> <assignedAuthor xsi:type="extPL:AssignedAuthor"> <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="true"/> <code code="0718_0726" codeSystem="2.16.840.1.113883.3.4424.11.3.3.1" displayName="neurologia, radiologia i diagnostyka obrazowa"/> <assignedPerson> <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/> <name> <prefix>lek.</prefix> <given>Piotr</given> <family>Nowak</family> </name> </assignedPerson> <representedOrganization> <templateId root="2.16.840.1.113883.3.4424.13.10.2.18"/> <id extension="000000001007-008" root="2.16.840.1.113883.3.4424.2.3.3" displayable="true"/> <name>Poradnia neurologiczna</name> <telecom use="PUB" value="tel:22-1111123"/> <addr> <postalCode>00-950</postalCode> <city>Warszawa</city> <streetName>Marszałkowska</streetName> <houseNumber>320</houseNumber> </addr> <asOrganizationPartOf> <wholeOrganization> <id extension="12345678901234" root="2.16.840.1.113883.3.4424.2.2.2" displayable="true"/> <asOrganizationPartOf> <wholeOrganization> <id extension="000000001007" root="2.16.840.1.113883.3.4424.2.3.1" displayable="true"/> <id extension="123456789" root="2.16.840.1.113883.3.4424.2.2.1" displayable="true"/> </wholeOrganization> </asOrganizationPartOf> </wholeOrganization> </asOrganizationPartOf> </representedOrganization> <extPL:boundedBy typeCode="PART"> <extPL:templateId root="2.16.840.1.113883.3.4424.13.10.2.44"/> <extPL:reimbursementRelatedContract moodCode="EVN" classCode="CNTRCT"> <extPL:id extension="3329978" root="2.16.840.1.113883.3.4424.8.6.1.7"/> <extPL:bounding typeCode="PART"> <extPL:reimburser classCode="UNDWRT"> <extPL:id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/> </extPL:reimburser> </extPL:bounding> </extPL:reimbursementRelatedContract> </extPL:boundedBy> </assignedAuthor> </author> <custodian> <templateId root="2.16.840.1.113883.3.4424.13.10.2.20"/> <assignedCustodian> <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"/> <time value="20130412"/> <signatureCode code="S"/> <assignedEntity> <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="false"/> </assignedEntity> </legalAuthenticator> <participant typeCode="IND"> <templateId root="2.16.840.1.113883.3.4424.13.10.2.19"/> <associatedEntity classCode="UNDWRT"> <id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/> </associatedEntity> </participant> <component> <templateId root="2.16.840.1.113883.3.4424.13.10.2.28"/> <structuredBody> <component> <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> <paragraph ID="OBS_1">I10 Nadciśnienie tętnicze</paragraph> </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="Nadciśnienie tętnicze (samoistne)"/> <text> <reference value="#OBS_1"/> </text> </observation> </component> </organizer> </entry> </section> </component> <component> <section> <templateId root="2.16.840.1.113883.3.4424.13.10.3.6"/> <code code="57828-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescriptions"/> <text> <paragraph ID="ENC_1"> Proszę o przyjęcie na oddział kardiologii w celu wykonania <content ID="PROC_1">koronarografii</content> </paragraph> </text> <entry> <templateId root="2.16.840.1.113883.3.4424.13.10.4.6"/> <encounter classCode="ENC" moodCode="RQO"> <code code="4100" codeSystem="2.16.840.1.113883.3.4424.11.2.4" displayName="Oddział kardiologiczny"/> <text> <reference value="#ENC_1"/> </text> <entryRelationship typeCode="COMP"> <procedure classCode="PROC" moodCode="RQO"> <code code="88.55" codeSystem="2.16.840.1.113883.3.4424.11.2.6" codeSystemName="ICD-9-PL" displayName="Koronarografia z użyciem jednego cewnika"/> <text> <reference value="#PROC_1"/> </text> </procedure> </entryRelationship> </encounter> </entry> </section> </component> <component> <section> <templateId root="2.16.840.1.113883.3.4424.13.10.3.39"/> <title>Załączniki</title> <text> <list> <item ID="EXTDOC_1">Wynik badania laboratoryjnego z dnia 01.10.2014</item> <item ID="EXTDOC_2">Wynik badania echokardiograficznego z dnia 09.09.2014</item> </list> </text> <entry> <organizer classCode="CLUSTER" moodCode="EVN"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.31"/> <statusCode code="completed"/> <reference typeCode="REFR"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.32"/> <seperatableInd value="false"/> <externalDocument> <templateId root="2.16.840.1.113883.3.4424.13.10.4.33"/> <id extension="2345678" root="2.16.840.1.113883.3.4424.2.7.0.7.1" displayable="false"/> <code code="11502-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Laboratory report"> <translation code="06.10" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Wyniki badań laboratoryjnych"/> </code> <text> <reference value="#EXTDOC_2"/> </text> <setId extension="432231" root="2.16.840.1.113883.3.4424.2.7.0.7.2"/> <versionNumber value="1"/> </externalDocument> </reference> <reference typeCode="REFR"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.32"/> <seperatableInd value="false"/> <externalDocument> <templateId root="2.16.840.1.113883.3.4424.13.10.4.34"/> <text> <reference value="#EXTDOC_2"/> </text> </externalDocument> </reference> </organizer> </entry> </section> </component> </structuredBody> </component></ClinicalDocument>`
Przykład |
Przykład
`<ClinicalDocument xsi:type="extPL:ClinicalDocument"> <!-- Skierowanie na rehabilitację kardiologiczną --> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root="2.16.840.1.113883.3.4424.13.10.1.4" extension="1.3.2"/> <id extension="2345678" root="2.16.840.1.113883.3.4424.7.4.1" displayable="false"/> <code code="57832-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for diagnostic or specialist care Document"> <translation code="02.10" displayName="Skierowanie na badanie lub leczenie" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1"/> </code> <title>Skierowanie na rehabilitację kardiologiczną</title> <effectiveTime value="20130412"/> <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/> <languageCode code="pl-PL"/> <setId extension="432231" root="2.16.840.1.113883.3.4424.7.4.2"/> <versionNumber value="1"/> <recordTarget> <templateId root="2.16.840.1.113883.3.4424.13.10.2.26"/> <patientRole> <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> </patientRole> </recordTarget> <author> <templateId root="2.16.840.1.113883.3.4424.13.10.2.86"/> <functionCode code="LEK" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Lekarz"/> <time value="20130412"/> <assignedAuthor xsi:type="extPL:AssignedAuthor"> <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="false"/> <code code="0718_0726" codeSystem="2.16.840.1.113883.3.4424.11.3.3.1" displayName="neurologia, radiologia i diagnostyka obrazowa"/> <assignedPerson> <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/> <name> <prefix>lek.</prefix> <given>Piotr</given> <family>Nowak</family> </name> </assignedPerson> <representedOrganization> <templateId root="2.16.840.1.113883.3.4424.13.10.2.17"/> <id extension="000000001007-01" root="2.16.840.1.113883.3.4424.2.3.2" displayable="true"/> <name>Poradnia POZ</name> <telecom use="PUB" value="tel:22-1111123"/> <addr> <postalCode>00-950</postalCode> <city>Warszawa</city> <streetName>Marszałkowska</streetName> <houseNumber>320</houseNumber> </addr> <asOrganizationPartOf> <wholeOrganization> <id extension="12345678901234" root="2.16.840.1.113883.3.4424.2.2.2" displayable="true"/> <name>NZOZ „POL-MED”</name> <asOrganizationPartOf> <wholeOrganization> <id extension="000000001007" root="2.16.840.1.113883.3.4424.2.3.1" displayable="true"/> <id extension="123456789" root="2.16.840.1.113883.3.4424.2.2.1" displayable="true"/> <name>POL-MED Sp. z o.o.</name> </wholeOrganization> </asOrganizationPartOf> </wholeOrganization> </asOrganizationPartOf> </representedOrganization> <extPL:boundedBy typeCode="PART"> <extPL:templateId root="2.16.840.1.113883.3.4424.13.10.2.44"/> <extPL:reimbursementRelatedContract moodCode="EVN" classCode="CNTRCT"> <extPL:id extension="123456" root="2.16.840.1.113883.3.4424.8.6.1.7"/> <extPL:bounding typeCode="PART"> <extPL:reimburser classCode="UNDWRT"> <extPL:id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/> </extPL:reimburser> </extPL:bounding> </extPL:reimbursementRelatedContract> </extPL:boundedBy> </assignedAuthor> </author> <custodian> <templateId root="2.16.840.1.113883.3.4424.13.10.2.20"/> <assignedCustodian> <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"/> <time value="20130412"/> <signatureCode code="S"/> <assignedEntity> <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="true"/> </assignedEntity> </legalAuthenticator> <component> <templateId root="2.16.840.1.113883.3.4424.13.10.2.28"/> <structuredBody> <component> <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> <paragraph> <content ID="OBS_1">I25.2 Przebyty zawał mięśnia sercowego ściany przedniej</content> <content ID="OBS_2">I10 Nadciśnienie tętnicze</content> </paragraph> </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="I25.2" codeSystem="2.16.840.1.113883.6.3" codeSystemName="icd10" displayName="Stary (przebyty) zawał serca"/> <text> <reference value="#OBS_1"/> </text> </observation> </component> </organizer> </entry> <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="#OBS_2"/> </text> </observation> </component> </organizer> </entry> </section> </component> <component> <section> <templateId root="2.16.840.1.113883.3.4424.13.10.3.6"/> <code code="57828-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescriptions"/> <text> <paragraph ID="ENC_1">Proszę o rehabilitację kardiologiczną u pacjenta po przebytym zawale ściany przedniej serca w styczniu br.</paragraph> </text> <entry> <templateId root="2.16.840.1.113883.3.4424.13.10.4.6"/> <encounter classCode="ENC" moodCode="RQO"> <code code="2300" codeSystem="2.16.840.1.113883.3.4424.11.2.4" displayName="Dzienny ośrodek rehabilitacji kardiologicznej"/> <text> <reference value="#ENC_1"/> </text> </encounter> </entry> </section> </component> </structuredBody> </component></ClinicalDocument>`
Przykład |
Przykład
`<ClinicalDocument xsi:type="extPL:ClinicalDocument"> <!-- Skierowanie na gastroskopię --> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root="2.16.840.1.113883.3.4424.13.10.1.4" extension="1.3.1"/> <id extension="1112223" root="2.16.840.1.113883.3.4424.7.4.1" displayable="false"/> <code code="57832-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for diagnostic or specialist care Document"> <translation code="02.10" displayName="Skierowanie na badanie lub leczenie" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1"/> </code> <title>Skierowanie na badanie endoskopowe</title> <effectiveTime value="20141001"/> <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/> <languageCode code="pl-PL"/> <setId extension="44444332" root="2.16.840.1.113883.3.4424.7.4.2"/> <versionNumber value="1"/> <recordTarget> <templateId root="2.16.840.1.113883.3.4424.13.10.2.26"/> <patientRole> <id extension="12345" root="2.16.840.1.113883.3.4424.2.7.0.17.1" displayable="false"/> <id extension="72020299999" root="2.16.840.1.113883.3.4424.1.1.616" displayable="true"/> <addr> <city>Warszawa</city> <postalCode>01-926</postalCode> <streetName>Kwitnąca</streetName> <houseNumber>6a</houseNumber> </addr> <patient> <name> <given>Józef</given> <family>Wojewódzki</family> </name> <birthTime value="19720202"/> </patient> </patientRole> </recordTarget> <author> <templateId root="2.16.840.1.113883.3.4424.13.10.2.86"/> <functionCode code="LEK" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Lekarz"/> <time value="20141001"/> <assignedAuthor xsi:type="extPL:AssignedAuthor"> <id extension="2355888" root="2.16.840.1.113883.3.4424.1.6.2" displayable="false"/> <code code="0743" codeSystem="2.16.840.1.113883.3.4424.11.3.3.1" displayName="gastroenterologia"/> <assignedPerson> <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/> <name> <prefix>dr n. med.</prefix> <given>Marian</given> <family>Walewski</family> </name> </assignedPerson> <representedOrganization> <templateId root="2.16.840.1.113883.3.4424.13.10.2.17"/> <id extension="000000001007-01" root="2.16.840.1.113883.3.4424.2.3.2" displayable="true"/> <name>Poradnia POZ</name> <telecom use="PUB" value="tel:22-1111123"/> <addr> <postalCode>00-950</postalCode> <city>Warszawa</city> <streetName>Marszałkowska</streetName> <houseNumber>320</houseNumber> </addr> <asOrganizationPartOf> <wholeOrganization> <id extension="12345678901234" root="2.16.840.1.113883.3.4424.2.2.2" displayable="true"/> <name>NZOZ „POL-MED”</name> <asOrganizationPartOf> <wholeOrganization> <id extension="000000001007" root="2.16.840.1.113883.3.4424.2.3.1" displayable="true"/> <id extension="123456789" root="2.16.840.1.113883.3.4424.2.2.1" displayable="true"/> <name>POL-MED Sp. z o.o.</name> </wholeOrganization> </asOrganizationPartOf> </wholeOrganization> </asOrganizationPartOf> </representedOrganization> <extPL:boundedBy typeCode="PART"> <extPL:templateId root="2.16.840.1.113883.3.4424.13.10.2.44"/> <extPL:reimbursementRelatedContract moodCode="EVN" classCode="CNTRCT"> <extPL:id extension="123456" root="2.16.840.1.113883.3.4424.8.6.1.7"/> <extPL:bounding typeCode="PART"> <extPL:reimburser classCode="UNDWRT"> <extPL:id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/> </extPL:reimburser> </extPL:bounding> </extPL:reimbursementRelatedContract> </extPL:boundedBy> </assignedAuthor> </author> <custodian> <templateId root="2.16.840.1.113883.3.4424.13.10.2.20"/> <assignedCustodian> <representedCustodianOrganization> <id root="2.16.840.1.113883.3.4424" assigningAuthorityName="CSIOZ" displayable="false"/> </representedCustodianOrganization> </assignedCustodian> </custodian> <informationRecipient typeCode="PRCP"> <templateId root="2.16.840.1.113883.3.4424.13.10.2.6"/> <intendedRecipient classCode="ASSIGNED"> <receivedOrganization> <templateId root="2.16.840.1.113883.3.4424.13.10.2.2"/> <id extension="000000001112-02" root="2.16.840.1.113883.3.4424.2.3.2" displayable="true"/> <name>Centrum Diagnostyki Endoskopowej</name> <telecom use="PUB" value="tel:22-343434555"/> <addr> <postalCode>00-345</postalCode> <city>Warszawa</city> <streetName>Spokojna</streetName> <houseNumber>112</houseNumber> </addr> </receivedOrganization> </intendedRecipient> </informationRecipient> <legalAuthenticator> <templateId root="2.16.840.1.113883.3.4424.13.10.2.6"/> <time value="20141001"/> <signatureCode code="S"/> <assignedEntity> <id extension="2355888" root="2.16.840.1.113883.3.4424.1.6.2" displayable="true"/> </assignedEntity> </legalAuthenticator> <participant typeCode="IND"> <templateId root="2.16.840.1.113883.3.4424.13.10.2.19"/> <associatedEntity classCode="UNDWRT"> <id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/> </associatedEntity> </participant> <component> <templateId root="2.16.840.1.113883.3.4424.13.10.2.28"/> <structuredBody> <component> <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>Rozpoznanie</title> <text> <paragraph> <content ID="OBS_1">D50.0 Niedokrwistość z niedoboru żelaza</content> </paragraph> </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="D50.0" codeSystem="2.16.840.1.113883.6.3" codeSystemName="icd10" displayName="Niedokrwistość z niedoboru żelaza spowodowana (przewlekłą) utratą krwi"/> <text> <reference value="#OBS_1"/> </text> </observation> </component> </organizer> </entry> </section> </component> <component> <section> <templateId root="2.16.840.1.113883.3.4424.13.10.3.6"/> <code code="57828-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescriptions"/> <text ID="ENC_1"> <paragraph> <caption>Rodzaj badania: </caption> <content ID="PROC_1">Gastroskopia</content> </paragraph> <paragraph> <caption>Cel badania (uzasadnienie): </caption> Diagnostyka przyczyny niedokrwistości. </paragraph> <paragraph> <caption>Badania dotychczas wykonane: </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> <entry> <templateId root="2.16.840.1.113883.3.4424.13.10.4.6"/> <encounter classCode="ENC" moodCode="RQO"> <code code="7910" codeSystem="2.16.840.1.113883.3.4424.11.2.4" displayName="Pracownia endoskopii"/> <text> <reference value="#ENC_1"/> </text> <entryRelationship typeCode="COMP"> <procedure classCode="PROC" moodCode="RQO"> <code code="44.16" codeSystem="2.16.840.1.113883.3.4424.11.2.6" codeSystemName="ICD-9-PL" displayName="Gastroskopia diagnostyczna"/> <text> <reference value="#PROC_1"/> </text> </procedure> </entryRelationship> </encounter> </entry> </section> </component> </structuredBody> </component></ClinicalDocument>`
Przykład |
Przykład
`<ClinicalDocument xsi:type="extPL:ClinicalDocument"> <!-- Skierowanie do poradni neurologicznej --> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root="2.16.840.1.113883.3.4424.13.10.1.4" extension="1.3.2"/> <id extension="99999" root="2.16.840.1.113883.3.4424.7.4.1" displayable="false"/> <code code="57133-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Referral note"> <translation code="02.11" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Skierowanie na konsultację"/> </code> <title>Skierowanie do poradni specjalistycznej</title> <effectiveTime value="20141010"/> <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/> <languageCode code="pl-PL"/> <setId extension="88888" root="2.16.840.1.113883.3.4424.7.4.2"/> <versionNumber value="1"/> <recordTarget> <templateId root="2.16.840.1.113883.3.4424.13.10.2.26"/> <patientRole> <id extension="123456" root="2.16.840.1.113883.3.4424.2.7.0.17.1" displayable="false"/> <id extension="42101099999" root="2.16.840.1.113883.3.4424.1.1.616" displayable="true"/> <addr> <city>Warszawa</city> <postalCode>01–809</postalCode> <streetName>Cegłowska</streetName> <houseNumber>80</houseNumber> </addr> <patient> <name> <given>Adrian</given> <given>Wiktor</given> <family>Cebulski</family> </name> <birthTime value="19421010"/> </patient> </patientRole> </recordTarget> <author> <templateId root="2.16.840.1.113883.3.4424.13.10.2.86"/> <functionCode code="LEK" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Lekarz"/> <time value="20141010"/> <assignedAuthor xsi:type="extPL:AssignedAuthor"> <id extension="2355000" root="2.16.840.1.113883.3.4424.1.6.2" displayable="false"/> <code code="0705" codeSystem="2.16.840.1.113883.3.4424.11.3.3.1" displayName="choroby wewnętrzne"/> <assignedPerson> <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/> <name> <prefix>lek.</prefix> <given>Adam</given> <family>Zadrożny</family> </name> </assignedPerson> <representedOrganization> <templateId root="2.16.840.1.113883.3.4424.13.10.2.18"/> <id extension="000000001007-031" root="2.16.840.1.113883.3.4424.2.3.3"/> <name>Ambulatorium Ogólne</name> <telecom use="PUB" value="tel:22-1111123"/> <addr> <postalCode>03-589</postalCode> <city>Warszawa</city> <streetName>Gilarska</streetName> <houseNumber>86c</houseNumber> </addr> <asOrganizationPartOf> <wholeOrganization> <id extension="12345678901234" root="2.16.840.1.113883.3.4424.2.2.2" displayable="true"/> <name>Oddział Zacisze</name> <telecom use="PUB" value="tel:22-1111125"/> <addr> <postalCode>03-683</postalCode> <city>Warszawa</city> <streetName>Tużycka</streetName> <houseNumber>13b</houseNumber> </addr> <asOrganizationPartOf> <wholeOrganization> <id extension="000000001007" root="2.16.840.1.113883.3.4424.2.3.1" displayable="true"/> <id extension="123456789" root="2.16.840.1.113883.3.4424.2.2.1" displayable="true"/> <name>Centrum Medyczne ENEL-MED Spółka Akcyjna</name> </wholeOrganization> </asOrganizationPartOf> </wholeOrganization> </asOrganizationPartOf> </representedOrganization> <extPL:boundedBy typeCode="PART"> <extPL:templateId root="2.16.840.1.113883.3.4424.13.10.2.44"/> <extPL:reimbursementRelatedContract moodCode="EVN" classCode="CNTRCT"> <extPL:id extension="654321" root="2.16.840.1.113883.3.4424.8.6.1.7"/> <extPL:bounding typeCode="PART"> <extPL:reimburser classCode="UNDWRT"> <extPL:id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/> </extPL:reimburser> </extPL:bounding> </extPL:reimbursementRelatedContract> </extPL:boundedBy> </assignedAuthor> </author> <custodian> <templateId root="2.16.840.1.113883.3.4424.13.10.2.20"/> <assignedCustodian> <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"/> <time value="20141010"/> <signatureCode code="S"/> <assignedEntity> <id extension="2355000" 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"/> </assignedEntity> </legalAuthenticator> <participant typeCode="IND"> <templateId root="2.16.840.1.113883.3.4424.13.10.2.19"/> <associatedEntity classCode="UNDWRT"> <id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/> </associatedEntity> </participant> <component> <templateId root="2.16.840.1.113883.3.4424.13.10.2.28"/> <structuredBody> <component> <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>Rozpoznanie</title> <text> <paragraph> <content ID="OBS_1">G54.4 Dyskopatia odcinka lędźwiowo-krzyżowego kręgosłupa na poziomie L5/S1</content> </paragraph> </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="G54.4" codeSystem="2.16.840.1.113883.6.3" codeSystemName="icd10" displayName="Zaburzenia korzeni nerwów rdzeniowych lędźwiowo-krzyżowych niesklasyfikowanych gdzie indziej"/> <text> <reference value="#OBS_1"/> </text> </observation> </component> </organizer> </entry> </section> </component> <component> <section> <templateId root="2.16.840.1.113883.3.4424.13.10.3.6"/> <code code="57828-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescriptions"/> <text ID="ENC_1"> <paragraph> Proszę o poradę specjalistyczną. </paragraph> <paragraph> <caption>Nazwa poradni: </caption> Poradnia neurologiczna </paragraph> <paragraph> <caption>Cel porady (uzasadnienie): </caption> Od trzech tygodni narastający ból okolicy lędźwiowo-krzyżowej kręgosłupa z promieniowaniem do prawej kończyny dolnej. Opadnięcie stopy prawej. Parestezje prawej kończyny dolnej. </paragraph> <paragraph> <caption>Badania dotychczas wykonane: </caption> W badaniu rezonansu magnetycznego odcinka L-S kręgosłupa centralno-prawoboczna przepuklina krążka międzykręgowego na poziomie L5/S1 zwężającq zachyłek boczny po stronie prawej z kompresją korzenia nerwowego. </paragraph> </text> <entry> <templateId root="2.16.840.1.113883.3.4424.13.10.4.6"/> <encounter classCode="ENC" moodCode="RQO"> <code code="1220" codeSystem="2.16.840.1.113883.3.4424.11.2.4" displayName="Poradnia neurologiczna"/> <text> <reference value="#ENC_1"/> </text> </encounter> </entry> </section> </component> </structuredBody> </component></ClinicalDocument>`
Przykład |
Przykład
`<ClinicalDocument xsi:type="extPL:ClinicalDocument"> <!-- Skierowanie na rehabilitację --> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root="2.16.840.1.113883.3.4424.13.10.1.4" extension="1.3.2"/> <id extension="11223344" root="2.16.840.1.113883.3.4424.7.4.1" displayable="false"/> <code code="57832-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for diagnostic or specialist care Document"> <translation code="02.10" displayName="Skierowanie na badanie lub leczenie" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1"/> </code> <title>Skierowanie na rehabilitację</title> <effectiveTime value="20141012"/> <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/> <languageCode code="pl-PL"/> <setId extension="443322" root="2.16.840.1.113883.3.4424.7.4.2"/> <versionNumber value="1"/> <recordTarget> <templateId root="2.16.840.1.113883.3.4424.13.10.2.26"/> <patientRole> <id extension="123456" root="2.16.840.1.113883.3.4424.2.7.0.17.1" displayable="false"/> <id extension="32101099999" root="2.16.840.1.113883.3.4424.1.1.616" displayable="true"/> <addr> <city>Warszawa</city> <postalCode>03–134</postalCode> <streetName>Książkowa 8d</streetName> <houseNumber>89</houseNumber> </addr> <patient> <name> <given>Adrian</given> <family>Kowalski</family> </name> <birthTime value="19321010"/> </patient> </patientRole> </recordTarget> <author> <templateId root="2.16.840.1.113883.3.4424.13.10.2.86"/> <functionCode code="LEK" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Lekarz"/> <time value="20141012"/> <assignedAuthor xsi:type="extPL:AssignedAuthor"> <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="false"/> <code code="0718_0726" codeSystem="2.16.840.1.113883.3.4424.11.3.3.1" displayName="neurologia, radiologia i diagnostyka obrazowa"/> <assignedPerson> <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/> <name> <prefix>lek.</prefix> <given>Piotr</given> <family>Nowak</family> </name> </assignedPerson> <representedOrganization> <templateId root="2.16.840.1.113883.3.4424.13.10.2.17"/> <id extension="000000001007-01" root="2.16.840.1.113883.3.4424.2.3.2" displayable="true"/> <name>Poradnia POZ</name> <telecom use="PUB" value="tel:22-1111123"/> <addr> <postalCode>00-950</postalCode> <city>Warszawa</city> <streetName>Marszałkowska</streetName> <houseNumber>320</houseNumber> </addr> <asOrganizationPartOf> <wholeOrganization> <id extension="12345678901234" root="2.16.840.1.113883.3.4424.2.2.2" displayable="true"/> <name>NZOZ „POL-MED”</name> <asOrganizationPartOf> <wholeOrganization> <id extension="000000001007" root="2.16.840.1.113883.3.4424.2.3.1" displayable="true"/> <id extension="123456789" root="2.16.840.1.113883.3.4424.2.2.1" displayable="true"/> <name>POL-MED Sp. z o.o.</name> </wholeOrganization> </asOrganizationPartOf> </wholeOrganization> </asOrganizationPartOf> </representedOrganization> <extPL:boundedBy typeCode="PART"> <extPL:templateId root="2.16.840.1.113883.3.4424.13.10.2.44"/> <extPL:reimbursementRelatedContract moodCode="EVN" classCode="CNTRCT"> <extPL:id extension="654321" root="2.16.840.1.113883.3.4424.8.6.1.7"/> <extPL:bounding typeCode="PART"> <extPL:reimburser classCode="UNDWRT"> <extPL:id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/> </extPL:reimburser> </extPL:bounding> </extPL:reimbursementRelatedContract> </extPL:boundedBy> </assignedAuthor> </author> <custodian> <templateId root="2.16.840.1.113883.3.4424.13.10.2.20"/> <assignedCustodian> <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"/> <time value="20141012"/> <signatureCode code="S"/> <assignedEntity> <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="true"/> </assignedEntity> </legalAuthenticator> <participant typeCode="IND"> <templateId root="2.16.840.1.113883.3.4424.13.10.2.19"/> <associatedEntity classCode="UNDWRT"> <id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/> </associatedEntity> </participant> <component> <templateId root="2.16.840.1.113883.3.4424.13.10.2.28"/> <structuredBody> <component> <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>Rozpoznanie</title> <text> <paragraph> <content ID="OBS_1">I69.3 Przebyty udar niedokrwienny mózgu pod postacią zespołu piramidowego prawostronnego</content> </paragraph> </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="I69.3" codeSystem="2.16.840.1.113883.6.3" codeSystemName="icd10" displayName="Następstwa zawału mózgu"/> <text> <reference value="#OBS_1"/> </text> </observation> </component> </organizer> </entry> </section> </component> <component> <section> <templateId root="2.16.840.1.113883.3.4424.13.10.3.6"/> <code code="57828-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescriptions"/> <text ID="ENC_1"> <paragraph> <caption>Cel porady (uzasadnienie): </caption> Proszę o kwalifikację do rehabilitacji poudarowej w warunkach domowych. Przebyty udar niedokrwienny mózgu pod postacią niedowładu piramidowego prawostronnego. </paragraph> </text> <entry> <templateId root="2.16.840.1.113883.3.4424.13.10.4.6"/> <encounter classCode="ENC" moodCode="RQO"> <code code="1300" codeSystem="2.16.840.1.113883.3.4424.11.2.4" displayName="Poradnia rehabilitacyja"/> <text> <reference value="#ENC_1"/> </text> </encounter> </entry> </section> </component> </structuredBody> </component></ClinicalDocument>`
Przykład |
Przykład
`<ClinicalDocument xsi:type="extPL:ClinicalDocument"> <!-- Skierowanie do laboratorium --> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root="2.16.840.1.113883.3.4424.13.10.1.4" extension="1.3.2"/> <id extension="654321" root="2.16.840.1.113883.3.4424.7.4.1" displayable="false"/> <code code="57832-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for diagnostic or specialist care Document"> <translation code="02.10" displayName="Skierowanie na badanie lub leczenie" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1"/> </code> <title>Skierowanie do laboratorium</title> <effectiveTime value="20130412"/> <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/> <languageCode code="pl-PL"/> <setId extension="123456" root="2.16.840.1.113883.3.4424.7.4.2"/> <versionNumber value="1"/> <recordTarget> <templateId root="2.16.840.1.113883.3.4424.13.10.2.26"/> <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="2.16.840.1.113883.3.4424.13.10.2.86"/> <functionCode code="LEK" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Lekarz"/> <time value="20130412"/> <assignedAuthor xsi:type="extPL:AssignedAuthor"> <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="false"/> <code code="0718_0726" codeSystem="2.16.840.1.113883.3.4424.11.3.3.1" displayName="neurologia, radiologia i diagnostyka obrazowa"/> <assignedPerson> <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/> <name> <prefix>lek.</prefix> <given>Piotr</given> <family>Nowak</family> </name> </assignedPerson> <representedOrganization> <templateId root="2.16.840.1.113883.3.4424.13.10.2.17"/> <id extension="000000001007-01" root="2.16.840.1.113883.3.4424.2.3.2" displayable="true"/> <name>Poradnia POZ</name> <telecom use="PUB" value="tel:22-1111123"/> <addr> <postalCode>00-950</postalCode> <city>Warszawa</city> <streetName>Marszałkowska</streetName> <houseNumber>320</houseNumber> </addr> <asOrganizationPartOf> <wholeOrganization> <id extension="12345678901234" root="2.16.840.1.113883.3.4424.2.2.2" displayable="true"/> <name>NZOZ „POL-MED”</name> <asOrganizationPartOf> <wholeOrganization> <id extension="000000001007" root="2.16.840.1.113883.3.4424.2.3.1" displayable="true"/> <id extension="123456789" root="2.16.840.1.113883.3.4424.2.2.1" displayable="true"/> <name>POL-MED Sp. z o.o.</name> </wholeOrganization> </asOrganizationPartOf> </wholeOrganization> </asOrganizationPartOf> </representedOrganization> <extPL:boundedBy typeCode="PART"> <extPL:templateId root="2.16.840.1.113883.3.4424.13.10.2.44"/> <extPL:reimbursementRelatedContract moodCode="EVN" classCode="CNTRCT"> <extPL:id extension="654321" root="2.16.840.1.113883.3.4424.8.6.1.7"/> <extPL:bounding typeCode="PART"> <extPL:reimburser classCode="UNDWRT"> <extPL:id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/> </extPL:reimburser> </extPL:bounding> </extPL:reimbursementRelatedContract> </extPL:boundedBy> </assignedAuthor> </author> <custodian> <templateId root="2.16.840.1.113883.3.4424.13.10.2.20"/> <assignedCustodian> <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"/> <time value="20130412"/> <signatureCode code="S"/> <assignedEntity> <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="true"/> </assignedEntity> </legalAuthenticator> <participant typeCode="IND"> <templateId root="2.16.840.1.113883.3.4424.13.10.2.19"/> <associatedEntity classCode="UNDWRT"> <id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="false"/> </associatedEntity> </participant> <component> <templateId root="2.16.840.1.113883.3.4424.13.10.2.28"/> <structuredBody> <component> <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> <paragraph ID="OBS_1">I10 Nadciśnienie tętnicze</paragraph> </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="Nadciśnienie tętnicze (samoistne)"/> <text> <reference value="#OBS_1"/> </text> </observation> </component> </organizer> </entry> </section> </component> <component> <section> <templateId root="2.16.840.1.113883.3.4424.13.10.3.6"/> <code code="57828-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescriptions"/> <text> <list ID="ENC_1"> <caption>Proszę o wykonanie następujących badań:</caption> <item ID="PROC_1">Morfologia krwi</item> <item ID="PROC_2">Sód (Na)</item> <item ID="PROC_3">Potas (K)</item> <item ID="PROC_4">Kreatynina</item> <item ID="PROC_5">Mocznik</item> </list> </text> <entry> <templateId root="2.16.840.1.113883.3.4424.13.10.4.6"/> <encounter classCode="ENC" moodCode="RQO"> <code code="7100" codeSystem="2.16.840.1.113883.3.4424.11.2.4" displayName="Pracownia diagnostyki laboratoryjnej (laboratorium)"/> <text> <reference value="#ENC_1"/> </text> <entryRelationship typeCode="COMP"> <procedure classCode="PROC" moodCode="RQO"> <code code="C53" codeSystem="2.16.840.1.113883.3.4424.11.2.6" codeSystemName="ICD-9-PL" displayName="Morfologia krwi 8-parametrowa"/> <text> <reference value="#PROC_1"/> </text> </procedure> </entryRelationship> <entryRelationship typeCode="COMP"> <procedure classCode="PROC" moodCode="RQO"> <code code="O35" codeSystem="2.16.840.1.113883.3.4424.11.2.6" codeSystemName="ICD-9-PL" displayName="Sód (Na)"/> <text> <reference value="#PROC_2"/> </text> </procedure> </entryRelationship> <entryRelationship typeCode="COMP"> <procedure classCode="PROC" moodCode="RQO"> <code code="N45" codeSystem="2.16.840.1.113883.3.4424.11.2.6" codeSystemName="ICD-9-PL" displayName="Potas (K)"/> <text> <reference value="#PROC_3"/> </text> </procedure> </entryRelationship> <entryRelationship typeCode="COMP"> <procedure classCode="PROC" moodCode="RQO"> <code code="M37" codeSystem="2.16.840.1.113883.3.4424.11.2.6" codeSystemName="ICD-9-PL" displayName="Kreatynina"/> <text> <reference value="#PROC_4"/> </text> </procedure> </entryRelationship> <entryRelationship typeCode="COMP"> <procedure classCode="PROC" moodCode="RQO"> <code code="N13" codeSystem="2.16.840.1.113883.3.4424.11.2.6" codeSystemName="ICD-9-PL" displayName="Mocznik"/> <text> <reference value="#PROC_5"/> </text> </procedure> </entryRelationship> </encounter> </entry> </section> </component> </structuredBody> </component></ClinicalDocument>`
Pozycja | Typ danych | Krotność | Wymagalność | Opis | Etykieta
--- | --- | --- | --- | --- | ---
`hl7:ClinicalDocument` |  | 1 … 1 | M |  | (plCral)
`@classCode` |  | 0 … 1 | F | DOCCLIN
`@moodCode` |  | 0 … 1 | F | EVN
`hl7:typeId` | II | 1 … 1 | M |  | (plCral)
`@extension` |  | 1 … 1 | F | POCD_HD000040
`@root` |  | 1 … 1 | F | 2.16.840.1.113883.1.3
`hl7:templateId` | II | 1 … 1 | M |  | (plCral)
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.13.10.1.4
`@extension` | st | 0 … 1 |  |
`hl7:id` | II | 1 … 1 | R |  | (plCral)
`@root` | uid | 1 … 1 | R |
`@extension` | st | 1 … 1 | R |
`hl7:code` | CE | 1 … 1 | M |  | (plCral)
| CONF |
Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.3.4424.13.11.33 Kod LOINC typu skierowania (DYNAMICZNE)
`hl7:translation` |  | 1 … 1 | M |  | (plCral)
| CONF |
Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.3.4424.13.11.24 Typ skierowania wg klasyfikacji dokumentów P1 (DYNAMICZNE)
`hl7:title` | ST | 1 … 1 | M |  | (plCral)
`hl7:effectiveTime` | TS | 1 … 1 | M |  | (plCral)
| Schematron assert | rola | error |
| test | concat(substring(@value,1,4),'-',substring(@value,5,2),'-',substring(@value,7,2)) castable as xs:date |
| Komunikat | Pierwsze 8 cyfr daty powinno być w formacie YYYYMMDD. |
`hl7:confidentialityCode` | CE | 1 … 1 | M |  | (plCral)
| CONF |
Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.1.11.16926 x_BasicConfidentialityKind (DYNAMICZNE)
`hl7:languageCode` | CS | 1 … 1 | M |  | (plCral)
`@code` | CONF | 1 … 1 | F | pl-PL
`hl7:setId` | II | 1 … 1 | M |  | (plCral)
`@root` | uid | 1 … 1 | R |
`@extension` | st | 1 … 1 | R |
`hl7:versionNumber` | INT | 1 … 1 | M |  | (plCral)
Dołączony | 1 … 1 | M | z 2.16.840.1.113883.3.4424.13.10.2.26 [2] Dane pacjenta dla dokumentu skierowania (DYNAMICZNE)
`hl7:recordTarget` |  | 1 … 1 | M |  | (plCral)
`@typeCode` |  | 0 … 1 | F | RCT
`@contextControlCode` |  | 0 … 1 | F | OP
`hl7:templateId` | II | 1 … 1 | M |  | (plCral)
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.13.10.2.26
`hl7:patientRole` |  | 1 … 1 | M |  | (plCral)
`@classCode` |  | 0 … 1 | F | PAT
`hl7:id` | II | 1 … * | M |  | (plCral)
`@root` | uid | 1 … 1 | R |
`@extension` | st | 1 … 1 | R |
| Schematron report | rola | error |
| test | @root='2.16.840.1.113883.3.4424.1.1.616' and not(matches(string(@extension),'^[0-9]{11}$')) |
| Komunikat | Jeżeli identyfikatorem jest numer PESEL, to musi zawierać 11 cyfr. |
| Schematron report | rola | warning |
| test | @root=('2.16.840.1.113883.3.4424.1.1','2.16.840.1.113883.3.4424.1.2','2.16.840.1.113883.3.4424.1.3','2.16.840.1.113883.3.4424.1.5') |
| Komunikat | Nieprawidłowa pula identyfikacji dla identyfikatora pacjenta. |
`hl7:addr` | AD.PL | 1 … 2 | R |  | (plCral)
`hl7:telecom` | TEL | 0 … * |  |  | (plCral)
| Przykład | Numer telefonu stacjonarnego `<telecom value="tel:(22)5690147"/>`
| Przykład | Numer telefonu komórkowego `<telecom value="tel:+48501234345"/>`
| Przykład | Numer faksu `<telecom value="fax:(22)5690239"/>`
| Przykład | Adres email `<telecom value="email:jan@kowalski.com"/>`
| Przykład | Numer telefonu komórkowego podany jako kontakt jedynie poprzez SMS `<telecom value="sms:+48501234345"/>`
`hl7:patient` |  | 1 … 1 | M |  | (plCral)
`@classCode` |  | 0 … 1 | F | PSN
`@determinerCode` |  | 0 … 1 | F | INSTANCE
`hl7:id` | II | 0 … * | NP |  | (plCral)
Dołączony | 1 … 1 | R | z 2.16.840.1.113883.3.4424.13.10.7.2 [7] Nazwisko i imię osoby (bazowy) (DYNAMICZNE)
`hl7:name` |  | 1 … 1 | R |  | (plCral)
`hl7:prefix` | ENXP | 0 … 1 |  |  | (plCral)
`hl7:given` | ENXP | 1 … * | R |  | (plCral)
`hl7:family` | ENXP | 1 … * | R |  | (plCral)
`hl7:administrativeGenderCode` | CE | 0 … 1 |  |  | (plCral)
| CONF |
Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.1.11.1 AdministrativeGender (DYNAMICZNE)
`hl7:birthTime` | TS.DATE | 0 … 1 |  |  | (plCral)
| Schematron assert | rola | error |
| test | concat(substring(@value,1,4),'-',substring(@value,5,2),'-',substring(@value,7,2)) castable as xs:date |
| Komunikat | Pierwsze 8 cyfr daty urodzenia powinno być w formacie YYYYMMDD. |
`hl7:guardian` |  | 0 … * |  |  | (plCral)
`@classCode` |  | 1 … 1 | F | GUARD
`hl7:id` | II | 0 … * |  |  | (plCral)
`@root` | uid | 1 … 1 | R |
`@extension` | st | 1 … 1 | R |
| Schematron report | rola | error |
| test | @root='2.16.840.1.113883.3.4424.1.1.616' and not(matches(string(@extension),'^[0-9]{11}$')) |
| Komunikat | Jeżeli identyfikatorem jest numer PESEL to musi zawierać 11 cyfr. |
| Schematron report | rola | warning |
| test | @root=('2.16.840.1.113883.3.4424.1.1','2.16.840.1.113883.3.4424.1.2','2.16.840.1.113883.3.4424.1.3','2.16.840.1.113883.3.4424.1.5') |
| Komunikat | Nieprawidłowa pula identyfikacji dla identyfikatora pacjenta. |
`hl7:code` | CE | 0 … 1 |  |  | (plCral)
`@codeSystem` | CONF | 0 … 1 | F | 2.16.840.1.113883.5.111
`hl7:addr` | AD.PL | 0 … * |  |  | (plCral)
Wybór | 1 … 1 |  | Elementy do wyboru z: hl7:guardianPerson zawierający szablon2.16.840.1.113883.3.4424.13.10.2.1 [2] Osoba (bazowy) (DYNAMICZNE) hl7:guardianOrganization zawierający szablon2.16.840.1.113883.3.4424.13.10.2.2 [2] Organizacja (bazowy) (DYNAMICZNE)
`hl7:guardianPerson` |  |  |  | Zawiera 2.16.840.1.113883.3.4424.13.10.2.1 [2] Osoba (bazowy) (DYNAMICZNE) | (plCral)
|  |  |  |  |  | gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.1']]
`hl7:guardianOrganization` |  |  |  | Zawiera 2.16.840.1.113883.3.4424.13.10.2.2 [2] Organizacja (bazowy) (DYNAMICZNE) | (plCral)
|  |  |  |  |  | gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.2']]
`extPL:multipleBirthInd` | BL | 0 … 1 |  |  | (plCral)
`extPL:multipleBirthOrderNumber` | INT.POS | 0 … 1 |  |  | (plCral)
| Schematron report | rola | error |
| test | extPL:multipleBirthInd/@value and not(extPL:multipleBirthOrderNumber/@value) |
| Komunikat | Dla ciąży mnogiej wymagane jest podanie numeru kolejności urodzenia. |
`hl7:providerOrganization` |  | 0 … 1 |  | Zawiera 2.16.840.1.113883.3.4424.13.10.2.2 [2] Organizacja (bazowy) (DYNAMICZNE) | (plCral)
|  |  | gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.2']]
| Schematron report | rola | error |
| test | count(hl7:addr) = 2 and not(count(hl7:addr[@use='PST']) = 1) |
| Komunikat | Jeżeli dokument zawiera dwa adresy pacjenta, to jeden z nich musi być adresem korespondencyjnym. |
Dołączony | 1 … 1 | M | z 2.16.840.1.113883.3.4424.13.10.2.86 [2] Autor dokumentu skierowania (DYNAMICZNE)
`hl7:author` |  | 1 … 1 | M |  | (plCral)
`@typeCode` |  | 0 … 1 | F | AUT
`@contextControlCode` |  | 0 … 1 | F | OP
`hl7:templateId` | II | 1 … 1 | M |  | (plCral)
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.13.10.2.86
`hl7:functionCode` | CE | 1 … 1 | R |  | (plCral)
| CONF |
Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.3.4424.13.11.37 Zawód medyczny (DYNAMICZNE)
`hl7:time` | TS | 1 … 1 | M |  | (plCral)
| Schematron assert | rola | error |
| test | (@value=/hl7:ClinicalDocument/hl7:legalAuthenticator/hl7:time/@value) or (@value=/hl7:ClinicalDocument/hl7:authenticator/hl7:time/@value) |
| Komunikat | Data utworzenia dokumentu powinna być taka sama jak data wystawienia lub autoryzacji dokumentu. |
`hl7:assignedAuthor` |  | 1 … 1 | R |  | (plCral)
`@classCode` |  | 0 … 1 | F | ASSIGNED
Wybór | 1 … 1 |  | Elementy do wyboru z: hl7:id[@root='2.16.840.1.113883.3.4424.1.6.2'] hl7:id[@root='2.16.840.1.113883.3.4424.1.6.3']
`hl7:id` | II | 0 … 1 |  |  | (plCral)
|  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.1.6.2']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.1.6.2
`@extension` | st | 1 … 1 | R |
`hl7:id` | II | 0 … 1 |  |  | (plCral)
|  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.1.6.3']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.1.6.3
`@extension` | st | 1 … 1 | R |
Wybór | 0 … 1 |  | Elementy do wyboru z: hl7:code[@codeSystem='2.16.840.1.113883.3.4424.11.3.3'] hl7:code[@codeSystem='2.16.840.1.113883.3.4424.11.3.3.1']
`hl7:code` | CE | 0 … 1 |  |  | (plCral)
|  |  |  | gdzie [@codeSystem='2.16.840.1.113883.3.4424.11.3.3']
| CONF |
Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.3.4424.13.11.21 Specjalizacja lekarza (DYNAMICZNE)
`hl7:code` | CE | 0 … 1 |  |  | (plCral)
|  |  |  | gdzie [@codeSystem='2.16.840.1.113883.3.4424.11.3.3.1']
`@code` | cs | 1 … 1 | R |
`@displayName` | st | 1 … 1 | R |
`@codeSystem` | CONF | 1 … 1 | F | 2.16.840.1.113883.3.4424.11.3.3.1 (Mnogie specjalności lekarskie)
`hl7:addr` | AD.PL | 0 … * |  |  | (plCral)
`hl7:telecom` | TEL | 0 … * |  |  | (plCral)
`hl7:assignedPerson` |  | 1 … 1 |  | Zawiera 2.16.840.1.113883.3.4424.13.10.2.1 [2] Osoba (bazowy) (DYNAMICZNE) | (plCral)
|  |  | gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.1']]
Wybór | 1 … 1 |  | Elementy do wyboru z: hl7:representedOrganization zawierający szablon2.16.840.1.113883.3.4424.13.10.2.15 [2] Praktyka medyczna (bazowy) (DYNAMICZNE) hl7:representedOrganization zawierający szablon2.16.840.1.113883.3.4424.13.10.2.17 [2] Jednostka podmiotu wykonującego działalność leczniczą (bazowy) (DYNAMICZNE) hl7:representedOrganization zawierający szablon2.16.840.1.113883.3.4424.13.10.2.18 [2] Komórka podmiotu wykonującego działalność leczniczą (bazowy) (DYNAMICZNE)
`hl7:representedOrganization` |  | 0 … 1 |  | Zawiera 2.16.840.1.113883.3.4424.13.10.2.15 [2] Praktyka medyczna (bazowy) (DYNAMICZNE) | (plCral)
|  |  |  | gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.15']]
`hl7:representedOrganization` |  | 0 … 1 |  | Zawiera 2.16.840.1.113883.3.4424.13.10.2.17 [2] Jednostka podmiotu wykonującego działalność leczniczą (bazowy) (DYNAMICZNE) | (plCral)
|  |  |  | gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.17']]
`hl7:representedOrganization` |  | 0 … 1 |  | Zawiera 2.16.840.1.113883.3.4424.13.10.2.18 [2] Komórka podmiotu wykonującego działalność leczniczą (bazowy) (DYNAMICZNE) | (plCral)
|  |  |  | gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.18']]
Dołączony | 0 … 1 |  | z 2.16.840.1.113883.3.4424.13.10.2.44 [2] Dane umowy związanej z refundacją (DYNAMICZNE)
`extPL:boundedBy` |  | 0 … 1 |  |  | (plCral)
`@typeCode` | cs | 1 … 1 | F | PART
`extPL:templateId` | II | 1 … 1 | M |  | (plCral)
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.13.10.2.44
`extPL:reimbursementRelatedContract` |  | 1 … 1 | M |  | (plCral)
`@classCode` | cs | 1 … 1 | F | CNTRCT
`@moodCode` | cs | 1 … 1 | F | EVN
Wybór | 1 … 1 |  | Elementy do wyboru z: extPL:id[@nullFlavor='NA'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.1'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.2'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.3'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.4'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.5'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.6'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.7'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.8'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.9'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.10'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.11'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.12'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.13'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.14'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.15'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.16'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.1'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.2'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.3'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.4'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.5'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.6'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.7'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.8'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.9'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.10'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.11'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.12'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.13'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.14'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.15'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.16'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.1'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.2'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.3'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.4'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.5'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.6'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.7'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.8'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.9'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.10'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.11'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.12'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.13'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.14'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.15'] extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.16']
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@nullFlavor='NA']
`@nullFlavor` | cs | 1 … 1 | F | NA
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.1']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.1.1
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.2']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.1.2
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.3']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.1.3
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.4']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.1.4
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.5']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.1.5
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.6']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.1.6
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.7']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.1.7
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.8']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.1.8
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.9']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.1.9
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.10']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.1.10
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.11']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.1.11
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.12']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.1.12
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.13']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.1.13
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.14']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.1.14
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.15']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.1.15
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.16']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.1.16
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.1']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.2.1
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.2']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.2.2
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.3']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.2.3
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.4']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.2.4
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.5']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.2.5
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.6']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.2.6
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.7']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.2.7
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.8']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.2.8
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.9']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.2.9
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.10']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.2.10
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.11']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.2.11
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.12']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.2.12
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.13']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.2.13
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.14']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.2.14
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.15']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.2.15
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.16']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.2.16
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.1']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.3.1
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.2']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.3.2
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.3']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.3.3
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.4']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.3.4
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.5']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.3.5
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.6']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.3.6
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.7']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.3.7
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.8']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.3.8
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.9']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.3.9
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.10']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.3.10
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.11']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.3.11
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.12']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.3.12
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.13']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.3.13
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.14']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.3.14
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.15']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.3.15
`@extension` | st | 1 … 1 | R |
`extPL:id` |  | 0 … 1 |  |  | (plCral)
|  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.16']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.8.6.3.16
`@extension` | st | 1 … 1 | R |
`extPL:code` |  | 0 … 1 |  |  | (plCral)
`extPL:bounding` |  | 1 … 1 | M |  | (plCral)
`@typeCode` | cs | 1 … 1 | F | PART
`extPL:reimburser` |  | 1 … 1 | M |  | (plCral)
`@classCode` | cs | 1 … 1 | F | UNDWRT
Wybór | 1 … 1 |  | Elementy do wyboru z: extPL:id[@root='2.16.840.1.113883.3.4424.3.1'] extPL:id[@root='1.0.3166.1'] extPL:id[@root='2.16.840.1.113883.3.4424.11.1.49']
`extPL:id` | II | 0 … 1 | R |  | (plCral)
|  |  |  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.3.1']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.3.1
`@extension` | st | 1 … 1 | R |
`extPL:id` | II | 0 … 1 | R |  | (plCral)
|  |  |  |  |  |  | gdzie [@root='1.0.3166.1']
`@root` | uid | 1 … 1 | F | 1.0.3166.1
`@extension` | st | 1 … 1 | R |
| Schematron assert | rola | warning |
| test | @extension=('AT','BE','BG','CY','CZ','DK','EE','FI','FR','GR','ES','NL','IS','IE','LI','LT','LU','LF','MT','DE','NO','PT','RO','SK','SI','CH','SE','HU','GB','IT','HR') |
| Komunikat | Nieprawidłowy identyfikator instytucji właściwej dla koordynacji |
`extPL:id` | II | 0 … 1 | R |  | (plCral)
|  |  |  |  |  |  | gdzie [@root='2.16.840.1.113883.3.4424.11.1.49']
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.11.1.49
`@extension` | st | 1 … 1 | R |
| Schematron report | rola | error |
| test | (hl7:id/@root='2.16.840.1.113883.3.4424.1.6.2' and not(hl7:functionCode/@code=('LEK','LEKD','FEL'))) or (hl7:id/@root='2.16.840.1.113883.3.4424.1.6.3' and not(hl7:functionCode/@code=('PIEL','POL'))) or (hl7:id/@root='2.16.840.1.113883.3.4424.1.6.1' and not(hl7:functionCode/@code=('FARM'))) or (hl7:id/@root='2.16.840.1.113883.3.4424.1.6.4' and not(hl7:functionCode/@code=('DLAB'))) |
| Komunikat | Wskazana pula numerów Prawa Wykonywania Zawodu jest nieprawidłowa w stosunku do wskazanego zawodu autora dokumentu. |
Dołączony | 0 … 1 |  | z 2.16.840.1.113883.3.4424.13.10.2.90 [2] Dane asystenta medycznego (DYNAMICZNE)
`hl7:dataEnterer` |  | 0 … 1 | R |  | (plCral)
`@typeCode` |  | 0 … 1 | F | ENT
`hl7:templateId` | II | 1 … 1 | M |  | (plCral)
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.13.10.2.90
`hl7:time` | TS | 0 … 1 |  |  | (plCral)
`hl7:assignedEntity` |  | 1 … 1 | M |  | (plCral)
`@classCode` |  | 0 … 1 | F | ASSIGNED
`hl7:id` | II | 1 … 1 | R |  | (plCral)
`hl7:addr` |  | 0 … 1 |  |  | (plCral)
`hl7:telecom` |  | 0 … 1 |  |  | (plCral)
`hl7:assignedPerson` |  | 1 … 1 | M | Zawiera 2.16.840.1.113883.3.4424.13.10.2.1 [2] Osoba (bazowy) (DYNAMICZNE) | (plCral)
|  |  | gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.1']]
`hl7:informant` |  |  | NP |  | (plCral)
Dołączony | 1 … 1 | M | z 2.16.840.1.113883.3.4424.13.10.2.20 [2] Organizacja odpowiedzialna za dokument dla P1 (DYNAMICZNE)
`hl7:custodian` |  | 1 … 1 | M |  | (plCral)
`@typeCode` |  | 0 … 1 | F | CST
`hl7:templateId` | II | 1 … 1 | M |  | (plCral)
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.13.10.2.20
`hl7:assignedCustodian` |  | 1 … 1 | M |  | (plCral)
`@classCode` |  | 0 … 1 | F | ASSIGNED
`hl7:representedCustodianOrganization` |  | 1 … 1 | M |  | (plCral)
`@classCode` |  | 0 … 1 | F | ORG
`@determinerCode` |  | 0 … 1 | F | INSTANCE
`hl7:id` | II | 1 … 1 | M |  | (plCral)
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424
`@extension` | st | 0 | NP | NP/nie występuje
`@assigningAuthorityName` | st | 1 … 1 | F | CSIOZ
`@displayable` | bl | 1 … 1 | R |
`hl7:name` | ON | 0 … * | NP |  | (plCral)
`hl7:telecom` | TEL | 0 … * | NP |  | (plCral)
`hl7:addr` | AD | 0 … * | NP |  | (plCral)
Dołączony | 0 … * |  | z 2.16.840.1.113883.3.4424.13.10.2.61 [2] Odbiorca informacji (bazowy) (DYNAMICZNE)
`hl7:informationRecipient` |  | 0 … * |  |  | (plCral)
`@typeCode` | cs | 1 … 1 | R |
| CONF |
Wartość @typeCode musi pochodzić ze zbioru wartości 2.16.840.1.113883.1.11.19366 x_InformationRecipient (DYNAMICZNE)
`hl7:templateId` | II | 1 … 1 | M |  | (plCral)
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.13.10.2.61
`hl7:intendedRecipient` |  | 1 … 1 |  |  | (plCral)
`@classCode` | cs | 1 … 1 | R |
| CONF |
@classCode musi mieć wartość "ASSIGNED"
`hl7:id` | II | 0 … * | R |  | (plCral)
`hl7:addr` | AD.PL | 0 … * |  |  | (plCral)
`hl7:telecom` | TEL | 0 … * |  |  | (plCral)
`hl7:informationRecipient` |  | 0 … 1 |  | Zawiera 2.16.840.1.113883.3.4424.13.10.2.1 [2] Osoba (bazowy) (DYNAMICZNE) | (plCral)
|  |  | gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.1']]
`hl7:receivedOrganization` |  | 1 … 1 | R | Zawiera 2.16.840.1.113883.3.4424.13.10.2.89 [2] Organizacja do której kierowany jest dokument (DYNAMICZNE) | (plCral)
|  |  | gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.89']]
Dołączony | 1 … 1 | M | z 2.16.840.1.113883.3.4424.13.10.2.6 [2] Wystawca dokumentu (bazowy) (DYNAMICZNE)
`hl7:legalAuthenticator` |  | 1 … 1 | M |  | (plCral)
`@typeCode` |  | 0 … 1 | F | LA
`@contextControlCode` |  | 0 … 1 | F | OP
`hl7:templateId` | II | 1 … 1 | M |  | (plCral)
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.13.10.2.6
`hl7:time` | TS | 1 … 1 | R |  | (plCral)
`hl7:signatureCode` | CS | 1 … 1 | R |  | (plCral)
| CONF |
Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMICZNE)
`hl7:assignedEntity` |  | 1 … 1 | M |  | (plCral)
`@classCode` |  | 0 … 1 | F | ASSIGNED
`hl7:id` | II | 1 … * | M |  | (plCral)
`@root` | uid | 1 … 1 | R |
`@extension` | st | 1 … 1 | R |
`hl7:code` | CE | 0 … 1 |  |  | (plCral)
`hl7:addr` | AD.PL | 0 … * |  |  | (plCral)
`hl7:telecom` | TEL | 0 … * |  |  | (plCral)
`hl7:assignedPerson` |  | 0 … 1 |  | Zawiera 2.16.840.1.113883.3.4424.13.10.2.1 [2] Osoba (bazowy) (DYNAMICZNE) | (plCral)
|  |  | gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.1']]
`hl7:representedOrganization` |  | 0 … 1 |  | Zawiera 2.16.840.1.113883.3.4424.13.10.2.2 [2] Organizacja (bazowy) (DYNAMICZNE) | (plCral)
|  |  | gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.2']]
| Schematron report | rola | error |
| test | not(hl7:assignedPerson/hl7:name) and not(hl7:id[@root=/hl7:ClinicalDocument/hl7:author/hl7:assignedAuthor/hl7:id/@root and @extension=/hl7:ClinicalDocument/hl7:author/hl7:assignedAuthor/hl7:id/@extension]) |
| Komunikat | Jeśli wystawca dokumentu jest również jego autorem to identyfikator wystawcy musi być taki sam jak identyfikator autora. W przeciwnym wypadku należy podać dane personalne wystawcy dokumentu. |
`hl7:authenticator` |  |  | NP |  | (plCral)
Dołączony | 0 … 1 |  | z 2.16.840.1.113883.3.4424.13.10.2.19 [2] Dane ubezpieczyciela publicznego (bazowy) (DYNAMICZNE)
`hl7:participant` |  | 0 … 1 |  |  | (plCral)
`@typeCode` | cs | 1 … 1 | F | IND
`@contextControlCode` |  | 0 … 1 | F | OP
`hl7:templateId` | II | 1 … 1 | M |  | (plCral)
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.13.10.2.19
`hl7:associatedEntity` |  | 1 … 1 | R |  | (plCral)
`@classCode` | cs | 1 … 1 | F | UNDWRT
Wybór | 1 … 1 |  | Elementy do wyboru z: hl7:id[@root='2.16.840.1.113883.3.4424.3.1'] hl7:id[@root='2.16.840.1.113883.3.4424.11.1.49']
`hl7:id` | II | 0 … 1 |  |  | (plCral)
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.3.1
`@extension` | st | 1 … 1 | R |
`hl7:id` | II | 0 … 1 |  |  | (plCral)
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.11.1.49
`@extension` | st | 1 … 1 | R |
Dołączony | 0 … * |  | z 2.16.840.1.113883.3.4424.13.10.2.53 [2] Dane zlecenia (bazowy) (DYNAMICZNE)
`hl7:inFulfillmentOf` |  | 0 … * |  |  | (plCral)
`@typeCode` |  | 0 … 1 | F | FLFS
`hl7:templateId` | II | 1 … 1 | M |  | (plCral)
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.13.10.2.53
`hl7:order` |  | 1 … 1 |  |  | (plCral)
`@classCode` |  | 0 … 1 | F | ACT
`@moodCode` |  | 1 … 1 | F | RQO
`hl7:id` | II | 1 … * | M |  | (plCral)
`hl7:code` | CE | 0 … 1 |  |  | (plCral)
`@codeSystem` | CONF | 0 … 1 | F | 2.16.840.1.113883.5.4 (ActCode)
`hl7:priorityCode` | CE | 0 … 1 |  |  | (plCral)
| CONF |
Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMICZNE)
`hl7:documentationOf` |  |  | NP |  | (plCral)
Dołączony | 0 … 1 |  | z 2.16.840.1.113883.3.4424.13.10.2.21 [2] Dokument powiązany dla P1 (DYNAMICZNE)
`hl7:relatedDocument` |  | 0 … 1 |  |  | (plCral)
`@typeCode` | cs | 1 … 1 | R |
| CONF |
@typeCode musi mieć wartość "RPLC"
lub
@typeCode musi mieć wartość "APND"
`hl7:templateId` | II | 1 … 1 | M |  | (plCral)
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.13.10.2.21
`hl7:parentDocument` |  | 1 … 1 | R |  | (plCral)
`@classCode` |  | 0 … 1 | F | DOCCLIN
`@moodCode` |  | 0 … 1 | F | EVN
`hl7:id` | II | 1 … 1 | M |  | (plCral)
`hl7:setId` | II | 1 … 1 | M |  | (plCral)
`hl7:versionNumber` | INT | 1 … 1 | M |  | (plCral)
| Schematron report | rola | error |
| test | hl7:id[@root=/hl7:ClinicalDocument/hl7:id/@root and @extension=/hl7:ClinicalDocument/hl7:id/@extension] |
| Komunikat | Idetyfikator dokumentu jest taki sam jak identyfikator dokumentu powiązanego wskazujcego na jego poprzednią wersję. |
| Schematron assert | rola | error |
| test | hl7:setId[@root=/hl7:ClinicalDocument/hl7:setId/@root and @extension=/hl7:ClinicalDocument/hl7:setId/@extension] |
| Komunikat | Identyfikator grupy wersji dokumentów (setId) powienien być identyczny dla dokumentu i dokumentu powiązanego wskazującego na jego poprzednią wersję. |
| Schematron assert | rola | error |
| test | (xs:integer(hl7:versionNumber/@value)+1)=xs:integer(/hl7:ClinicalDocument/hl7:versionNumber/@value) |
| Komunikat | Dokument powiązany powienien wskazywać poprzednią wersję dokumentu. |
`hl7:authorization` |  |  | NP |  | (plCral)
`hl7:componentOf` |  |  | NP |  | (plCral)
Dołączony | 1 … 1 | M | z 2.16.840.1.113883.3.4424.13.10.2.28 [2] Treść dokumentu skierowania (DYNAMICZNE)
`hl7:component` |  | 1 … 1 | M |  | (plCral)
`@typeCode` |  | 0 … 1 | F | COMP
`@contextConductionInd` | bl | 0 … 1 |  |
`hl7:templateId` | II | 1 … 1 | M |  | (plCral)
`@root` | uid | 1 … 1 | F | 2.16.840.1.113883.3.4424.13.10.2.28
Wybór | 1 … 1 |  | Elementy do wyboru z: hl7:structuredBody[hl7:component[hl7:section[hl7:templateId[@root='2.16.840.1.113883.3.4424.13.10.3.55']]]] hl7:structuredBody[not(hl7:component[hl7:section[hl7:templateId[@root='2.16.840.1.113883.3.4424.13.10.3.55']]])]
`hl7:structuredBody` |  | 0 … 1 |  |  | (plCral)
|  |  | gdzie [hl7:component [hl7:section [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.3.55']]]]
`@classCode` |  | 0 … 1 | F | DOCBODY
`@moodCode` |  | 0 … 1 | F | EVN
`hl7:component` |  | 1 … 1 | M | Zawiera 2.16.840.1.113883.3.4424.13.10.3.57 [3] Sekcja postaci binarnej dokumentu skierowania (DYNAMICZNE) | (plCral)
|  |  |  | gdzie [hl7:section [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.3.57']]]
`@typeCode` |  | 0 … 1 | F | COMP
| Schematron assert | rola | error |
| test | not(hl7:component[not(hl7:section/hl7:templateId/@root='2.16.840.1.113883.3.4424.13.10.3.55')]) |
| Komunikat | Jeżeli w dokumencie znajduje się sekcja postaci binarnej dokumentu, to nie może występować sekcja innego typu. |
`hl7:structuredBody` |  | 0 … 1 |  |  | (plCral)
|  |  | gdzie [not(hl7:component [hl7:section [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.3.55']]])]
`@classCode` |  | 0 … 1 | F | DOCBODY
`@moodCode` |  | 0 … 1 | F | EVN
`hl7:component` |  | 0 … 1 |  | Zawiera 2.16.840.1.113883.3.4424.13.10.3.1 [3] Sekcja rozpoznań (DYNAMICZNE) | (plCral)
|  |  |  | gdzie [hl7:section [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.3.1']]]
`@typeCode` |  | 0 … 1 | F | COMP
`hl7:component` |  | 0 … 1 |  | Zawiera 2.16.840.1.113883.3.4424.13.10.3.7 [3] Sekcja aktualnych wyników badań (DYNAMICZNE) | (plCral)
|  |  |  | gdzie [hl7:section [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.3.7']]]
`@typeCode` |  | 0 … 1 | F | COMP
`hl7:component` |  | 1 … 1 | M | Zawiera 2.16.840.1.113883.3.4424.13.10.3.6 [3] Sekcja główna skierowania (DYNAMICZNE) | (plCral)
|  |  |  | gdzie [hl7:section [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.3.6']]] [not(@nullFlavor)]
`@typeCode` |  | 0 … 1 | F | COMP
`hl7:component` |  | 0 … * | R | Zawiera 2.16.840.1.113883.3.4424.13.10.3.69 [3] Sekcja danych ubezpieczeniowych (DYNAMICZNE) | (plCral)
|  |  |  | gdzie [hl7:section [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.3.69']]]
`@typeCode` |  | 0 … 1 | F | COMP
`hl7:component` |  | 0 … 1 |  | Zawiera 2.16.840.1.113883.3.4424.13.10.3.39 [3] Sekcja załączników (DYNAMICZNE) | (plCral)
|  |  |  | gdzie [hl7:section [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.3.39']]]
`@typeCode` |  | 0 … 1 | F | COMP
| Schematron report | rola | error |
| test | count(//(hl7:observation|hl7:substanceAdministration|hl7:supply|hl7:procedure|hl7:encounter|hl7:act|hl7:externalDocument)[not(ancestor::hl7:section/hl7:templateId[@root='2.16.840.1.113883.3.4424.13.10.3.55']) and not(ancestor::hl7:entryRelationship) and not(hl7:text/hl7:reference)])>0 |
| Komunikat | Element text dla danego wyrażenia klinicznego jest wymagany, ze wskazaniem referencji do odpowiedniego elementu section.text. |
| Zmienna let | Nazwa | versionLabel |
| Wartość | '1.3.2' |
| Schematron assert | rola | error |
| test | count(hl7:templateId[@root and @extension=$versionLabel])=1 |
| Komunikat | Nie występuje prawidłowe oznaczenie zgodności dokumentu z daną wersją wydania Polskiej Implementacji Krajowej HL7 CDA. |
| Schematron assert | rola | error |
| test | /processing-instruction('xml-stylesheet') = concat('href="CDA_PL_IG_',/hl7:ClinicalDocument/hl7:templateId[@extension]/@extension,'.xsl" type="text/xsl"') |
| Komunikat | Nieprawidłowe wskazanie transformaty generującej warstwę prezentacyjną dokumentu. |