Polska Implementacja Krajowa HL7 CDA (plcda-)

eZdrowie - Projekt P1

Przykłady - [1] Dokument recepty spełniający wymagania związane z refundacją

Dokument recepty spełniający wymagania związane z refundacją 1

<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="2.16.840.1.113883.3.4424.13.10.1.26" extension="1.2.2"/>
  <id extension="de343d" 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="Rpz" 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="20130412"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="pl-PL"/>
  <setId extension="ff543" 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="2.16.840.1.113883.3.4424.13.10.2.79"/>
    <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="1007-008" 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="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>
      <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"/>
      <code code="LEK" codeSystem="2.16.840.1.113883.3.4424.11.3.18" displayName="Lekarz"/>
    </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="9876" 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">
               Rilutek 50mg tabletki (
              <content ID="ACT_1">NZ</content>
              )
              <br/>
               1 op. po 56 tabl.
              <br/>
               D.S. 2 x 1 tabl.
              <br/>
              <content ID="ACT_2">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"/>
              <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="de343d-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="20130412"/>
                <high nullFlavor="NA"/>
              </effectiveTime>
              <repeatNumber value="1"/>
              <doseQuantity 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="7897" codeSystem="2.16.840.1.113883.3.4424.6.1" displayName="Rilutek 50mg tabl. powl."/>
                    <name>Rilutek 50mg tabl. powl.; 0,05 g 56 tabl. </name>
                    <pharm:asContent classCode="CONT">
                      <pharm:containerPackagedMedicine classCode="CONT" determinerCode="INSTANCE">
                        <pharm:code code="5909990760619" codeSystem="1.3.160" codeSystemName="GS1"/>
                        <pharm:name>Rilutek 50mg tabl. powl. (56 tabl.)</pharm:name>
                        <pharm:formCode code="ORTAB" codeSystem="2.16.840.1.113883.5.1127" displayName="Oral Tablet"/>
                        <pharm:capacityQuantity value="56"/>
                      </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="20130412"/>
                  <priorityCode code="UR" codeSystem="2.16.840.1.113883.5.7"/>
                  <independentInd value="false"/>
                  <quantity value="1"/>
                  <product>
                    <manufacturedProduct>
                      <manufacturedLabeledDrug>
                        <code code="5909990760619" codeSystem="1.3.160" codeSystemName="GS1"/>
                      </manufacturedLabeledDrug>
                    </manufacturedProduct>
                  </product>
                  <entryRelationship typeCode="COMP">
                    <act classCode="ACT" moodCode="DEF">
                      <templateId root="2.16.840.1.113883.3.4424.13.10.4.57"/>
                      <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">
                          <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"/>
                              <value code="100%" codeSystem="2.16.840.1.113883.3.4424.11.1.1" displayName="pełnopłatne"/>
                            </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>
              <entryRelationship typeCode="COMP">
                <act classCode="ACT" moodCode="DEF">
                  <templateId root="1.3.6.1.4.1.19376.1.9.1.3.9.1"/>
                  <templateId root="2.16.840.1.113883.3.4424.13.10.4.56"/>
                  <code code="N" codeSystem="2.16.840.1.113883.5.1070" codeSystemName="HL7 Substance Admin Substitution"/>
                  <text>
                    <reference value="#ACT_1"/>
                  </text>
                  <statusCode code="completed"/>
                </act>
              </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_3">
               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_3"/>
              </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_3"/>
                  </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="de343d-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 spełniający wymagania zwiazane z refundacją 2

<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="2.16.840.1.113883.3.4424.13.10.1.26" extension="1.2.2"/>
  <id extension="aa2321" 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="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="20130412"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="pl-PL"/>
  <setId extension="64324" 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="2.16.840.1.113883.3.4424.13.10.2.79"/>
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        <name>
          <prefix>lek. dent.</prefix>
          <given>Damian</given>
          <family>Kowalski</family>
        </name>
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        <id extension="000000054325-01" root="2.16.840.1.113883.3.4424.2.4.68.1"/>
        <name>Prywatna praktyka dentystyczna Damian Kowalski</name>
        <telecom use="PUB" value="tel:22-4325678"/>
        <addr>
          <country>Polska</country>
          <postalCode>03-135</postalCode>
          <city>Warszawa</city>
          <streetName>Książkowa</streetName>
          <houseNumber>9F</houseNumber>
          <unitID>1</unitID>
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            <name>Prywatna praktyka dentystyczna Damian Kowalski</name>
            <telecom use="PUB" value="tel:22-4325678"/>
            <addr>
              <country>Polska</country>
              <postalCode>03-135</postalCode>
              <city>Warszawa</city>
              <streetName>Książkokwa</streetName>
              <houseNumber>9F</houseNumber>
              <unitID>1</unitID>
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          <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">
               Enarenal 5mg tabletki
              <br/>
               1 op. po 60 tabl.
              <br/>
               D.S. 2 x 1 tabl.
              <br/>
              <content ID="ACT_1">Odpłatność: R</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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              <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.1"/>
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              <id extension="aa2321-1" root="2.16.840.1.113883.3.4424.2.7.99999.2.3"/>
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                <reference value="#SBADM_1"/>
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              <statusCode code="completed"/>
              <effectiveTime xsi:type="IVL_TS">
                <low value="20130412"/>
                <high nullFlavor="NA"/>
              </effectiveTime>
              <repeatNumber value="1"/>
              <doseQuantity value="1"/>
              <consumable>
                <manufacturedProduct>
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                    <templateId root="1.3.6.1.4.1.19376.1.9.1.3.1"/>
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                    <code code="4321" codeSystem="2.16.840.1.113883.3.4424.6.1" displayName="Enarenal 5mg tabl."/>
                    <name>Enarenal 5mg tabletki</name>
                  </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="20130505"/>
                  <priorityCode code="UR" codeSystem="2.16.840.1.113883.5.7"/>
                  <independentInd value="false"/>
                  <quantity value="1"/>
                  <product>
                    <manufacturedProduct>
                      <manufacturedLabeledDrug>
                        <code code="5909990014958" codeSystem="1.3.160" codeSystemName="GS1"/>
                      </manufacturedLabeledDrug>
                    </manufacturedProduct>
                  </product>
                  <entryRelationship typeCode="COMP">
                    <act classCode="ACT" moodCode="DEF">
                      <templateId root="2.16.840.1.113883.3.4424.13.10.4.57"/>
                      <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" displayName="Payment source"/>
                      <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"/>
                              <value code="R" codeSystem="2.16.840.1.113883.3.4424.11.1.1" displayName="ryczałt"/>
                            </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>
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        </section>
      </component>
      <component>
        <section>
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          <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">
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              <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 -->
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                  <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"/>
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                  <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"/>
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                      <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="aa2321-1" root="2.16.840.1.113883.3.4424.2.7.99999.2.3"/>
                          <consumable>
                            <manufacturedProduct>
                              <manufacturedMaterial nullFlavor="NA"/>
                            </manufacturedProduct>
                          </consumable>
                        </substanceAdministration>
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                    </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>