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ref Szablon  [2] Treść dokumentu recepty

ID 2.16.840.1.113883.3.4424.13.10.2.25 Data obowiązywania obowiązuje od 2018‑06‑30
Status active Active Etykieta wersji 1.3
Nazwa plCdaDrugPrescriptionComponent Nazwa wyświetlana [2] Treść dokumentu recepty
Opis Bazowy szablon struktury CDA dla treści medycznej recepty
Kontekst Węzły nadrzędne elementu szablonu o id 2.16.840.1.113883.3.4424.13.10.2.25
Typ CDA Header Level Template
Otwarty/Zamknięty Otwarty (pozostałe elementy poza zdefiniowanymi są dozwolone)
Używane przez / Używa
Używane przez Transakcje 0 i szablony 3, Używa 2 szablonów
Używane przez jako Nazwa Wersja
2.16.840.1.113883.3.4424.13.10.1.26 Zawierać active [1] Recepta spełniająca wymagania związane z refundacją (1.3.2) 2020‑06‑08
2.16.840.1.113883.3.4424.13.10.1.3 Zawierać active [1] Recepta (1.3.2) 2020‑06‑08
2.16.840.1.113883.3.4424.13.10.1.7 Zawierać active [1] Recepta farmaceutyczna (1.3.2) 2020‑06‑08
Używa jako Nazwa Wersja
2.16.840.1.113883.3.4424.13.10.3.4 Ograniczanie active [3] Sekcja zalecenia leku (1.3) DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.3.69 Ograniczanie active [3] Sekcja danych ubezpieczeniowych (1.3) DYNAMICZNE
Relacje Specialization: szablon 2.16.840.1.113883.3.4424.13.10.2.22 (2017‑01‑02)
Przykład
Przykład
<component>
  <templateId root="2.16.840.1.113883.3.4424.13.10.2.25"/>  <structuredBody>
    <component>
      <section>
        <templateId root="1.3.6.1.4.1.19376.1.9.1.2.1"/>        <templateId root="2.16.840.1.113883.3.4424.13.10.3.4"/>        <id extension="4321" root="2.16.840.1.113883.3.4424.2.7.99999.2.4"/>        <code code="57828-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescriptions"/>        <title>Rp.</title>        <text>
          <paragraph ID="SBADM_1">
             Polocard 150mg tabletki            <br/>             1 op. po 60 tabl.            <br/>             Odpłatność: 100%            <br/>             D.S. 1 x 1 tabl. rano           </paragraph>        </text>        <entry>
          <substanceAdministration classCode="SBADM" moodCode="INT">
            <templateId root="1.3.6.1.4.1.19376.1.9.1.3.2"/>            <templateId root="2.16.840.1.113883.10.20.1.24"/>            <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7"/>            <templateId root="1.3.6.1.4.1.19376.1.9.1.3.6"/>            <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.1"/>            <templateId root="2.16.840.1.113883.3.4424.13.10.4.3"/>            <id extension="876543-1" root="2.16.840.1.113883.3.4424.2.7.99999.2.3"/>            <text>
              <reference value="#SBADM_1"/>            </text>            <statusCode code="completed"/>            <effectiveTime xsi:type="IVL_TS">
              <low value="20171012"/>              <high nullFlavor="NA"/>            </effectiveTime>            <repeatNumber value="1"/>            <consumable>
              <manufacturedProduct>
                <templateId root="2.16.840.1.113883.10.20.1.53"/>                <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.2"/>                <manufacturedMaterial>
                  <templateId root="1.3.6.1.4.1.19376.1.9.1.3.1"/>                  <templateId root="2.16.840.1.113883.3.4424.13.10.4.54"/>                  <code code="5679" codeSystem="2.16.840.1.113883.3.4424.6.1" displayName="Polocard 150mg tabletki"/>                  <name>Polocard 150mg tabletki</name>                  <pharm:asContent classCode="CONT">
                    <pharm:containerPackagedMedicine classCode="CONT" determinerCode="INSTANCE">
                      <pharm:code code="5909990655007" codeSystem="1.3.160" codeSystemName="GS1"/>                      <pharm:name>Polocard 150mg (60 tabl.)</pharm:name>                      <pharm:formCode code="ORTAB" codeSystem="2.16.840.1.113883.5.1127" displayName="Oral Tablet"/>                      <pharm:capacityQuantity value="60"/>                    </pharm:containerPackagedMedicine>                  </pharm:asContent>                </manufacturedMaterial>              </manufacturedProduct>            </consumable>            <entryRelationship typeCode="COMP">
              <supply classCode="SPLY" moodCode="RQO">
                <templateId root="1.3.6.1.4.1.19376.1.9.1.3.8"/>                <templateId root="2.16.840.1.113883.3.4424.13.10.4.55"/>                <effectiveTime value="20171012"/>                <independentInd value="false"/>                <quantity value="1"/>                <product>
                  <manufacturedProduct>
                    <manufacturedLabeledDrug>
                      <code code="5909990655007" codeSystem="1.3.160" codeSystemName="GS1" displayName="Polocard 150mg (60 tabl.)"/>                    </manufacturedLabeledDrug>                  </manufacturedProduct>                </product>              </supply>            </entryRelationship>          </substanceAdministration>        </entry>      </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"/>        <title>Dane o ubezpieczeniu i uprawnieniach</title>        <text>
          <paragraph ID="ACT_2">
             Oddział NFZ: 07             <br/>             Uprawnienia dodatkowe: ZK (Nr leg.: 238/2015)           </paragraph>        </text>        <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_2"/>            </text>            <statusCode code="completed"/>            <entryRelationship typeCode="COMP">
              <act classCode="ACT" moodCode="EVN">
                <!-- Uprawnienie dodatkowe -->
                <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_2"/>                </text>                <statusCode code="completed"/>                <performer typeCode="PRF">
                  <!-- Dane ubezpieczyciela/płatnika -->
                  <assignedEntity>
                    <id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/>                  </assignedEntity>                </performer>                <entryRelationship typeCode="REFR">
                  <act classCode="ACT" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.1.19"/>                    <templateId root="2.16.840.1.113883.3.4424.13.10.4.53"/>                    <id nullFlavor="NA"/>                    <code nullFlavor="NA"/>                    <entryRelationship typeCode="SUBJ">
                      <substanceAdministration classCode="SBADM" moodCode="PRMS">
                        <id extension="2345678-1" root="2.16.840.1.113883.3.4424.2.7.99999.2.3"/>                        <consumable>
                          <manufacturedProduct>
                            <manufacturedMaterial nullFlavor="NA"/>                          </manufacturedProduct>                        </consumable>                      </substanceAdministration>                    </entryRelationship>                  </act>                </entryRelationship>                <reference typeCode="REFR">
                  <externalAct classCode="ACT" moodCode="EVN">
                    <!-- Informacja o dokumencie potwierdzającym uprawnienie dodatkowe -->
                    <templateId root="2.16.840.1.113883.3.4424.13.10.4.58"/>                    <id extension="123" root="2.16.840.1.113883.3.4424.8.4"/>                    <code code="ELG" codeSystem="2.16.840.1.113883.5.4" displayName="Eligible"/>                  </externalAct>                </reference>              </act>            </entryRelationship>          </act>        </entry>      </section>    </component>  </structuredBody></component>
Pozycja Typ danych Krotność Wymagalność Opis Etykieta
hl7:component
 1 … 1 R (plCdotsent)
@typeCode
 0 … 1 F COMP
@contextConductionInd
 bl 0 … 1  
hl7:templateId
 II 1 … 1 M (plCdotsent)
@root
 uid 1 … 1 F 2.16.840.1.113883.3.4424.13.10.2.25
hl7:structuredBody
 1 … 1 M (plCdotsent)
@classCode
 0 … 1 F DOCBODY
@moodCode
 0 … 1 F EVN
hl7:component
 1 … 1 M Zawiera 2.16.840.1.113883.3.4424.13.10.3.4 [3] Sekcja zalecenia leku (DYNAMICZNE) (plCdotsent)
treeblank treeblank gdzie [hl7:section [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.3.4']]] [not(@nullFlavor)]
hl7:component
 0 … * R Zawiera 2.16.840.1.113883.3.4424.13.10.3.69 [3] Sekcja danych ubezpieczeniowych (DYNAMICZNE) (plCdotsent)
treeblank treeblank gdzie [hl7:section [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.3.69']]]
hl7:component
 0 … * (plCdotsent)
treeblank treeblank gdzie [hl7:section/hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2']
hl7:section
 (plCdotsent)
hl7:templateId
 (plCdotsent)
treeblank treeblank treeblank treeblank gdzie [@root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2']
@root
 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
hl7:component
 0 … * (plCdotsent)
treeblank treeblank gdzie [hl7:section/hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.13']
hl7:section
 (plCdotsent)
hl7:templateId
 (plCdotsent)
treeblank treeblank treeblank treeblank gdzie [@root='1.3.6.1.4.1.19376.1.5.3.1.3.13']
@root
 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.3.13
hl7:component
 0 … * (plCdotsent)
treeblank treeblank gdzie [hl7:section/hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.6']
hl7:section
 (plCdotsent)
hl7:templateId
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treeblank treeblank treeblank treeblank gdzie [@root='1.3.6.1.4.1.19376.1.5.3.1.3.6']
@root
 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.3.6
hl7:component
 0 … * (plCdotsent)
treeblank treeblank gdzie [hl7:section/hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.8']
hl7:section
 (plCdotsent)
hl7:templateId
 (plCdotsent)
treeblank treeblank treeblank treeblank gdzie [@root='1.3.6.1.4.1.19376.1.5.3.1.3.8']
@root
 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.3.8
hl7:component
 0 … * (plCdotsent)
treeblank treeblank gdzie [hl7:section/hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.23']
hl7:section
 (plCdotsent)
hl7:templateId
 (plCdotsent)
treeblank treeblank treeblank treeblank gdzie [@root='1.3.6.1.4.1.19376.1.5.3.1.3.23']
@root
 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.3.23
hl7:component
 0 … * (plCdotsent)
treeblank treeblank gdzie [hl7:section/hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4']
hl7:section
 (plCdotsent)
hl7:templateId
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treeblank treeblank treeblank treeblank gdzie [@root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4']
@root
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  Schematron report rola red 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.