Przykłady - [1] Dokument recepty
Dokument recepty na lek OTC
<ClinicalDocument>
<!-- Recepta na Enarenal zgodna z profilem IHE PRE -->
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<code code="57833-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for medication Document">
<translation code="04.01" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Recepta">
<qualifier>
<name code="KDLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Kategoria dostępności leku"/>
<value code="Rp" codeSystem="2.16.840.1.113883.3.4424.11.1.25"/>
</qualifier>
<qualifier>
<name code="RLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Rodzaj leku"/>
<value code="G" displayName="Lek gotowy" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/>
</qualifier>
<qualifier>
<name code="TWREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb wystawienia recepty"/>
<value code="Z" displayName="Zwykła" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/>
</qualifier>
<qualifier>
<name code="TRREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb realizacji recepty"/>
<value code="Z" displayName="Zwykły" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/>
</qualifier> </translation> </code>
<title>Recepta</title>
<effectiveTime value="20171012"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="pl-PL"/>
<setId extension="432231" root="2.16.840.1.113883.3.4424.2.7.99999.2.1"/>
<versionNumber value="1"/>
<recordTarget>
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<patientRole>
<id extension="12345" root="2.16.840.1.113883.3.4424.2.7.99999.17.1" displayable="false"/>
<id extension="62091599999" root="2.16.840.1.113883.3.4424.1.1.616" displayable="true"/>
<addr>
<country>Polska</country>
<postalCode xsi:type="extPL:adxp.postalCode" postCity="Piaseczno">03-134</postalCode>
<city>Warszawa</city>
<streetName>Odkryta</streetName>
<houseNumber>41</houseNumber>
<unitID>12</unitID>
<censusTract>TERYT SIMC: 987654</censusTract>
</addr>
<patient>
<name>
<given>Jan</given>
<given>Franciszek</given>
<family>Kowalski</family>
</name>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>
<birthTime value="19620915"/>
</patient> </patientRole> </recordTarget>
<author>
<templateId root="2.16.840.1.113883.3.4424.13.10.2.82"/>
<functionCode code="FEL" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Felczer"/>
<assignedAuthor>
<id extension="98765" root="2.16.840.1.113883.3.4424.1.6.2" displayable="true"/>
<assignedPerson>
<templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/>
<name>
<given>Adam</given>
<family>Kowalski</family>
</name> </assignedPerson>
<representedOrganization>
<templateId root="2.16.840.1.113883.3.4424.13.10.2.17"/>
<id extension="1007-01" 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"/>
<asOrganizationPartOf>
<wholeOrganization>
<id extension="1007" 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> </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"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="98765" root="2.16.840.1.113883.3.4424.1.6.2" displayable="true"/>
</assignedEntity> </legalAuthenticator>
<component>
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<section>
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<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
1 op. po 60 tabl.
Odpłatność: 100%
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"/>
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<text>
<reference value="#SBADM_1"/>
</text>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS">
</effectiveTime>
<repeatNumber value="1"/>
<consumable>
<manufacturedProduct>
<templateId root="2.16.840.1.113883.10.20.1.53"/>
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<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"/>
<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"/>
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<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 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"/>
<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 -->
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<templateId root="2.16.840.1.113883.3.4424.13.10.4.61"/>
<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"/>
<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">
<externalDocument classCode="DOC" moodCode="EVN">
<!-- Informacja o dokumencie potwierdzającym uprawnienie dodatkowe -->
<templateId root="2.16.840.1.113883.3.4424.13.10.4.59"/>
<text>Nr leg.: 234/1992</text>
</externalDocument> </reference> </act> </entryRelationship> </act> </entry> </section> </component> </structuredBody> </component> </ClinicalDocument>
Dokument recepty na lek recepturowy
<ClinicalDocument>
<!-- Recepta na Enarenal zgodna z profilem IHE PRE -->
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
<templateId root="1.3.6.1.4.1.19376.1.9.1.1.1"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.1"/>
<templateId root="2.16.840.1.113883.3.4424.13.10.1.3" extension="1.2.2"/>
<id extension="b876543" root="2.16.840.1.113883.3.4424.2.7.99999.2.1" displayable="true"/>
<code code="57833-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for medication Document">
<translation code="04.01" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Recepta">
<qualifier>
<name code="KDLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Kategoria dostępności leku"/>
<value code="Rp" codeSystem="2.16.840.1.113883.3.4424.11.1.25"/>
</qualifier>
<qualifier>
<name code="RLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Rodzaj leku"/>
<value code="R" displayName="Lek recepturowy" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/>
</qualifier>
<qualifier>
<name code="TWREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb wystawienia recepty"/>
<value code="PL" displayName="Pielęgniarska na zlecenie lekarza" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/>
</qualifier>
<qualifier>
<name code="TRREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb realizacji recepty"/>
<value code="Z" displayName="Zwykły" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/>
</qualifier> </translation> </code>
<title>Recepta pielęgniarska na zlecenie lekarza</title>
<effectiveTime value="20171012"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="pl-PL"/>
<setId extension="432231" root="2.16.840.1.113883.3.4424.2.7.99999.2.1"/>
<versionNumber value="1"/>
<recordTarget>
<templateId root="2.16.840.1.113883.3.4424.13.10.2.23"/>
<patientRole>
<id extension="12345" root="2.16.840.1.113883.3.4424.2.7.99999.17.1" displayable="false"/>
<id extension="62091599999" root="2.16.840.1.113883.3.4424.1.1.616" displayable="true"/>
<addr>
<country>Polska</country>
<postalCode xsi:type="extPL:adxp.postalCode" postCity="Piaseczno">03-134</postalCode>
<city>Warszawa</city>
<streetName>Odkryta</streetName>
<houseNumber>41</houseNumber>
<unitID>12</unitID>
<censusTract>TERYT SIMC: 987654</censusTract>
</addr>
<patient>
<name>
<given>Jan</given>
<given>Franciszek</given>
<family>Kowalski</family>
</name>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>
<birthTime value="19620915"/>
</patient> </patientRole> </recordTarget>
<author>
<templateId root="2.16.840.1.113883.3.4424.13.10.2.82"/>
<functionCode code="PIEL" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Pielęgniarka"/>
<assignedAuthor>
<id extension="89765" root="2.16.840.1.113883.3.4424.1.6.3" displayable="true"/>
<assignedPerson>
<templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/>
<name>
<given>Zuzanna</given>
<family>Wyszyńska</family>
</name> </assignedPerson>
<representedOrganization>
<templateId root="2.16.840.1.113883.3.4424.13.10.2.17"/>
<id extension="1007-01" 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"/>
<asOrganizationPartOf>
<wholeOrganization>
<id extension="1007" 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> </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"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="89765" root="2.16.840.1.113883.3.4424.1.6.3" displayable="true"/>
</assignedEntity> </legalAuthenticator>
<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="322122" 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. (Cito)</title>
<text>
<paragraph ID="SBADM_1">
Lanolini
Vaselini albi
Paraffini liq.
Aquae aa ad 100.0
M.f. unguentum
D.S. Miejscowo na skórę, nałożyć cienką warstwę
<content>Odpłatność: 100%</content>
</paragraph> </text>
<entry>
<substanceAdministration classCode="SBADM" moodCode="INT">
<templateId root="1.3.6.1.4.1.19376.1.9.1.3.2"/>
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<id extension="b876543-1" 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">
</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="2.16.840.1.113883.3.4424.13.10.4.70"/>
<templateId root="1.3.6.1.4.1.19376.1.9.1.3.1"/>
<name>Maść pośladkowa</name>
<pharm:formCode code="TOPOINT" codeSystem="2.16.840.1.113883.5.1127" displayName="Topical Ointment"/>
<pharm:ingredient classCode="ACTI">
<templateId root="2.16.840.1.113883.3.4424.13.10.4.71"/>
<pharm:ingredient classCode="MMAT" determinerCode="KIND">
<pharm:code code="23432" codeSystem="2.16.1.113383.3.4424.6.3" displayName="Wazelina biała"/>
<pharm:name>Vaselinum album</pharm:name>
</pharm:ingredient> </pharm:ingredient>
<pharm:ingredient classCode="ACTI">
<templateId root="2.16.840.1.113883.3.4424.13.10.4.71"/>
<pharm:ingredient classCode="MMAT" determinerCode="KIND">
<pharm:code code="34543" codeSystem="2.16.1.113383.3.4424.6.3" displayName="Lanolina"/>
<pharm:name>Lanolinum</pharm:name>
</pharm:ingredient> </pharm:ingredient>
<pharm:ingredient classCode="ACTI">
<templateId root="2.16.840.1.113883.3.4424.13.10.4.71"/>
<pharm:ingredient classCode="MMAT" determinerCode="KIND">
<pharm:code code="45654" codeSystem="2.16.1.113383.3.4424.6.3" displayName="Parafina ciekła"/>
<pharm:name>Paraffinum liquidum</pharm:name>
</pharm:ingredient> </pharm:ingredient>
<pharm:ingredient classCode="ACTI">
<templateId root="2.16.840.1.113883.3.4424.13.10.4.71"/>
<pharm:ingredient classCode="MMAT" determinerCode="KIND">
<pharm:code code="56765" codeSystem="2.16.1.113383.3.4424.6.3" displayName="Woda do receptury aptecznej FP"/>
<pharm:name>Aqua</pharm:name>
</pharm:ingredient> </pharm:ingredient> </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="100" unit="g"/>
</supply> </entryRelationship> </substanceAdministration> </entry> </section> </component>
<component>
<section>
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<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 Uprawnienia dodatkowe: ZK (Nr leg.: 238/2015) </paragraph> </text>
<entry>
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<text>
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<statusCode code="completed"/>
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<act classCode="ACT" moodCode="EVN">
<!-- Uprawnienie dodatkowe -->
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<text>
<reference value="#ACT_2"/>
</text>
<statusCode code="completed"/>
<performer typeCode="PRF">
<!-- Dane ubezpieczyciela/płatnika -->
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<act classCode="ACT" moodCode="EVN">
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<entryRelationship typeCode="SUBJ">
<substanceAdministration classCode="SBADM" moodCode="PRMS">
<id extension="b876543-1" 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">
<externalDocument classCode="DOC" moodCode="EVN">
<!-- Informacja o dokumencie potwierdzającym uprawnienie dodatkowe -->
<templateId root="2.16.840.1.113883.3.4424.13.10.4.59"/>
<text>Nr leg.: 234/1992</text>
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Dokument recepty na środek spożywczy
<ClinicalDocument>
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<qualifier>
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<value code="S" displayName="Środek spożywczy specjalnego przeznaczenia żywieniowego" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/>
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<qualifier>
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<value code="P" displayName="Pielęgniarska" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/>
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<qualifier>
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<value code="Z" displayName="Zwykły" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/>
</qualifier> </translation> </code>
<title>Recepta pielęgniarska</title>
<effectiveTime value="20171022"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="pl-PL"/>
<setId extension="xu2432" root="2.16.840.1.113883.3.4424.2.7.99999.2.1"/>
<versionNumber value="1"/>
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<addr>
<country>Polska</country>
<postalCode xsi:type="extPL:adxp.postalCode" postCity="Piaseczno">03-134</postalCode>
<city>Warszawa</city>
<streetName>Odkryta</streetName>
<houseNumber>41</houseNumber>
<unitID>12</unitID>
<censusTract>TERYT SIMC: 987654</censusTract>
</addr>
<patient>
<name>
<given>Jan</given>
<given>Franciszek</given>
<family>Kowalski</family>
</name>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>
<birthTime value="19620915"/>
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<author>
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<name>
<given>Anna</given>
<family>Wyszyńska</family>
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<id extension="000000046985-01" root="2.16.840.1.113883.3.4424.2.5.9.1"/>
<name>Praktyka pielęgniarska Anna Wyszyńska</name>
<telecom use="PUB" value="tel:22-1111123"/>
<telecom use="PUB" value="fax:22-1111100"/>
<addr>
<country>Polska</country>
<postalCode>00-950</postalCode>
<city>Warszawa</city>
<streetName>Litewska</streetName>
<houseNumber>18</houseNumber>
</addr>
<asOrganizationPartOf>
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<name>Praktyka pielęgniarska Anna Wyszyńska</name>
<telecom use="PUB" value="tel:58-4443322"/>
<addr>
<country>Polska</country>
<postalCode>80-401</postalCode>
<city>Gdańsk</city>
<streetName>Al. gen. Józefa Hallera</streetName>
<houseNumber>15</houseNumber>
</addr> </wholeOrganization> </asOrganizationPartOf> </representedOrganization> </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>
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<signatureCode code="S"/>
<assignedEntity>
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<component>
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<structuredBody>
<component>
<section>
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<code code="57828-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescriptions"/>
<title>Rp.</title>
<text>
<paragraph ID="SBADM_1">
Nutrison Advanced Protison płyn
14 op. po 500 ml
D.S. 1000ml podawane do gastrostomii przezskórnej (PEG) przez 12 godzin
<content ID="ACT_1">Odpłatność: 100%</content>
</paragraph> </text>
<entry>
<substanceAdministration classCode="SBADM" moodCode="INT">
<templateId root="1.3.6.1.4.1.19376.1.9.1.3.2"/>
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<text>
<reference value="#SBADM_1"/>
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<effectiveTime xsi:type="IVL_TS">
</effectiveTime>
<repeatNumber value="1"/>
<doseQuantity value="1"/>
<consumable>
<manufacturedProduct>
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<name>Nutrison Advanced Protison płyn 500ml</name>
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<entryRelationship typeCode="COMP">
<supply classCode="SPLY" moodCode="RQO">
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<effectiveTime value="20171022"/>
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<independentInd value="false"/>
<product>
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<entryRelationship typeCode="COMP">
<act classCode="ACT" moodCode="DEF">
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<text>
<reference value="#ACT_1"/>
</text>
<statusCode code="completed"/>
<entryRelationship typeCode="COMP">
<act classCode="ACT" moodCode="EVN">
<code code="PUBLICPOL" codeSystem="2.16.840.1.113883.5.4">
<qualifier>
<name code="RLPO" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Poziomy odpłatności leków refundowanych"/>
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</qualifier> </code>
<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> </act> </entryRelationship> </act> </entryRelationship> </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"/>
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<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
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"/>
<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 -->
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<templateId root="2.16.840.1.113883.3.4424.13.10.4.61"/>
<code code="PUBLICPOL" codeSystem="2.16.840.1.113883.5.4">
<qualifier>
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<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">
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<entryRelationship typeCode="SUBJ">
<supply classCode="SPLY" moodCode="PRMS">
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<reference typeCode="REFR">
<externalDocument classCode="DOC" moodCode="EVN">
<!-- Informacja o dokumencie potwierdzającym uprawnienie dodatkowe -->
<templateId root="2.16.840.1.113883.3.4424.13.10.4.59"/>
<text>Nr leg.: 234/1992</text>
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