Primjer dokumenta Otpusno pismo nakon hitnog prijema u bolnicu
{ "resourceType": "Bundle", "id": "2222", "meta": { "versionId": "4", "lastUpdated": "03/10/2023 11:58:58", "source": "#0d3a1308d9c47852" }, "identifier": { "system": "urn:ietf:rfc:3986", "value": "urn:oid:2.16.840.1.113883.2.7.50.2.1.600600" }, "type": "document", "timestamp": "02/28/2023 22:12:21", "entry": [ { "fullUrl": "urn:uuid:1137f7d9-a1c4-4523-95ad-e2423b01ce48", "resource": { "resourceType": "Composition", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Composition</b></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"/><p><b>status</b>: final</p><p><b>type</b>: Otpusno pismo nakon hitnog prijema u bolnicu <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-document-type.html\">Tip dokumenta</a>#006)</span></p><p><b>encounter</b>: <a href=\"#urnuuidf4b4d96d-0e60-48d4-b8eb-60f8dd2b59e2\">See above (urn:uuid:f4b4d96d-0e60-48d4-b8eb-60f8dd2b59e2)</a></p><p><b>date</b>: 2023-02-28 22:12:21+0000</p><p><b>author</b>: </p><ul><li><a href=\"#urnuuid0b2d4e02-4096-439e-9a05-355f8d997e45\">See above (urn:uuid:0b2d4e02-4096-439e-9a05-355f8d997e45: Doktor Davor)</a></li><li><a href=\"#urnuuid33a64feb-08d3-436f-a300-82326ecde4be\">See above (urn:uuid:33a64feb-08d3-436f-a300-82326ecde4be: Bolnica 1)</a></li></ul><p><b>title</b>: Nalaz nakon hitnog prijema u bolnicu</p><blockquote><p><b>attester</b></p><p><b>mode</b>: professional</p><p><b>party</b>: <a href=\"#urnuuid0b2d4e02-4096-439e-9a05-355f8d997e45\">See above (urn:uuid:0b2d4e02-4096-439e-9a05-355f8d997e45: Doktor Davor)</a></p></blockquote><blockquote><p><b>attester</b></p><p><b>mode</b>: official</p><p><b>party</b>: <a href=\"#urnuuid33a64feb-08d3-436f-a300-82326ecde4be\">See above (urn:uuid:33a64feb-08d3-436f-a300-82326ecde4be: Bolnica 1)</a></p></blockquote></div>" }, "status": "final", "type": { "coding": [ { "system": "http://fhir.cezih.hr/specifikacije/CodeSystem/document-type", "code": "006", "display": "Otpusno pismo nakon hitnog prijema u bolnicu" } ] }, "subject": { "reference": "urn:uuid:fc19e23e-0ea7-4c73-a550-54d15808fe15", "display": "Ivo Ivić" }, "encounter": { "reference": "urn:uuid:f4b4d96d-0e60-48d4-b8eb-60f8dd2b59e2" }, "date": "02/28/2023 22:12:21", "author": [ { "reference": "urn:uuid:0b2d4e02-4096-439e-9a05-355f8d997e45", "display": "Doktor Davor" }, { "reference": "urn:uuid:33a64feb-08d3-436f-a300-82326ecde4be", "display": "Bolnica 1" } ], "title": "Nalaz nakon hitnog prijema u bolnicu", "attester": [ { "mode": "professional", "party": { "reference": "urn:uuid:0b2d4e02-4096-439e-9a05-355f8d997e45", "display": "Doktor Davor" } }, { "mode": "official", "party": { "reference": "urn:uuid:33a64feb-08d3-436f-a300-82326ecde4be", "display": "Bolnica 1" } } ], "section": [ { "title": "Djelatnost", "code": { "coding": [ { "system": "http://fhir.cezih.hr/specifikacije/CodeSystem/document-section", "code": "12", "display": "Djelatnost" } ] }, "entry": [ { "reference": "urn:uuid:2a8e22b3-465e-4a65-96f0-d3890693ce36" } ] }, { "title": "Priloženi dokumenti", "code": { "coding": [ { "system": "http://fhir.cezih.hr/specifikacije/CodeSystem/document-section", "code": "16", "display": "Priloženi dokumenti" } ] }, "entry": [ { "reference": "urn:uuid:b05a4d6e-94ba-4703-831b-ba03ef32223d" } ] }, { "title": "Medicinska informacija", "code": { "coding": [ { "system": "http://fhir.cezih.hr/specifikacije/CodeSystem/document-section", "code": "18", "display": "Medicinska informacija" } ] }, "entry": [ { "reference": "urn:uuid:ae0bc20e-9811-4088-9765-0102e360b3ae" }, { "reference": "urn:uuid:272c293d-48ec-4396-96b0-e80014c65317" }, { "reference": "urn:uuid:b908ceec-8db3-4859-b4c4-926980c655b4" }, { "reference": "urn:uuid:2d0a28e9-4009-4ee4-8224-7e1220d85507" }, { "reference": "urn:uuid:55247671-086a-423a-8cb5-0557abbe9622" } ] } ] } }, { "fullUrl": "urn:uuid:f4b4d96d-0e60-48d4-b8eb-60f8dd2b59e2", "resource": { "resourceType": "Encounter", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Encounter</b></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"/><p><b>identifier</b>: id: cl3lnsp4o000009mhcuac4j0u</p><p><b>status</b>: in-progress</p><p><b>class</b>: Interna uputnica (Details: http://fhir.cezih.hr/specifikacije/CodeSystem/nacin-prijema code 9 = 'Interna uputnica', stated as 'Interna uputnica')</p><p><b>priority</b>: routine <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-v3-ActPriority.html\">ActPriority</a>#R)</span></p><p><b>subject</b>: <span/></p><blockquote><p><b>participant</b></p><p><b>individual</b>: <span/></p></blockquote><blockquote><p><b>participant</b></p><p><b>individual</b>: <span/></p></blockquote><p><b>period</b>: 2022-01-20 12:30:02+0000 --> 2022-02-01 12:30:02+0000</p><h3>Diagnoses</h3><table class=\"grid\"><tr><td>-</td><td><b>Condition</b></td></tr><tr><td>*</td><td><span/></td></tr></table><p><b>serviceProvider</b>: <span/></p></div>" }, "identifier": [ { "system": "http://fhir.cezih.hr/specifikacije/identifikatori/identifikator-posjete", "value": "cl3lnsp4o000009mhcuac4j0u" } ], "status": "in-progress", "class": { "system": "http://fhir.cezih.hr/specifikacije/CodeSystem/nacin-prijema", "code": "9", "display": "Interna uputnica" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ActPriority", "code": "R" } ] }, "subject": { "type": "Patient", "identifier": { "system": "http://fhir.cezih.hr/specifikacije/identifikatori/MBO", "value": "180223069" } }, "participant": [ { "individual": { "type": "Practitioner", "identifier": { "system": "http://fhir.cezih.hr/specifikacije/identifikatori/HZJZ-broj-zdravstvenog-djelatnika", "value": "1234567" } } }, { "individual": { "type": "Practitioner", "identifier": { "system": "http://fhir.cezih.hr/specifikacije/identifikatori/HZJZ-broj-zdravstvenog-djelatnika", "value": "7654321" } } } ], "period": { "start": "01/20/2022 12:30:02", "end": "02/01/2022 12:30:02" }, "diagnosis": [ { "condition": { "type": "Condition", "identifier": { "system": "http://fhir.cezih.hr/specifikacije/identifikatori/slucaj", "value": "cl3lndh7u000009l6hhzya349" } } } ], "serviceProvider": { "type": "Organization", "identifier": { "system": "http://fhir.cezih.hr/specifikacije/identifikatori/HZZO-sifra-zdravstvene-organizacije", "value": "1234" } } } }, { "fullUrl": "urn:uuid:0b2d4e02-4096-439e-9a05-355f8d997e45", "resource": { "resourceType": "Practitioner", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Practitioner</b></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"/><p><b>identifier</b>: id: 1234567</p><p><b>name</b>: Doktor Davor </p></div>" }, "identifier": [ { "system": "http://fhir.cezih.hr/specifikacije/identifikatori/HZJZ-broj-zdravstvenog-djelatnika", "value": "1234567" } ], "name": [ { "family": "Davor", "given": [ "Doktor" ] } ] } }, { "fullUrl": "urn:uuid:33a64feb-08d3-436f-a300-82326ecde4be", "resource": { "resourceType": "Organization", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Organization</b></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"/><p><b>identifier</b>: id: 1234</p><p><b>name</b>: Bolnica 1</p></div>" }, "identifier": [ { "system": "http://fhir.cezih.hr/specifikacije/identifikatori/HZZO-sifra-zdravstvene-organizacije", "value": "1234" } ], "name": "Bolnica 1" } }, { "fullUrl": "urn:uuid:fc19e23e-0ea7-4c73-a550-54d15808fe15", "resource": { "resourceType": "Patient", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table class=\"hapiPropertyTable\"><tbody><tr><td>Identifier</td><td>180223069</td></tr></tbody></table></div>" }, "identifier": [ { "system": "http://fhir.cezih.hr/specifikacije/identifikatori/MBO", "value": "180223069" } ] } }, { "fullUrl": "urn:uuid:2a8e22b3-465e-4a65-96f0-d3890693ce36", "resource": { "resourceType": "HealthcareService", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: HealthcareService</b></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"/><p><b>identifier</b>: id: 3030000</p><p><b>providedBy</b>: <a href=\"#urnuuid33a64feb-08d3-436f-a300-82326ecde4be\">See above (urn:uuid:33a64feb-08d3-436f-a300-82326ecde4be)</a></p><p><b>name</b>: Onkologija</p></div>" }, "identifier": [ { "system": "http://fhir.cezih.hr/specifikacije/identifikatori/ID-djelatnosti", "value": "3030000" } ], "providedBy": { "reference": "urn:uuid:33a64feb-08d3-436f-a300-82326ecde4be" }, "name": "Onkologija" } }, { "fullUrl": "urn:uuid:b05a4d6e-94ba-4703-831b-ba03ef32223d", "resource": { "resourceType": "DocumentReference", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: DocumentReference</b></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"/><p><b>status</b>: current</p><blockquote><p><b>content</b></p><h3>Attachments</h3><table class=\"grid\"><tr><td>-</td><td><b>ContentType</b></td><td><b>Data</b></td><td><b>Title</b></td></tr><tr><td>*</td><td>application/pdf</td><td>UERGIG5hbGF6IGJhc2U2NCBlbmtvZGlyYW4u</td><td>Neki dokument</td></tr></table></blockquote></div>" }, "status": "current", "content": [ { "attachment": { "contentType": "application/pdf", "data": "UERGIG5hbGF6IGJhc2U2NCBlbmtvZGlyYW4u", "title": "Neki dokument" } } ] } }, { "fullUrl": "urn:uuid:ae0bc20e-9811-4088-9765-0102e360b3ae", "resource": { "resourceType": "Observation", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Observation</b></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"/><p><b>status</b>: final</p><p><b>code</b>: Anamneza <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-observations.html\">Observacije</a>#15)</span></p><p><b>subject</b>: <span/></p><p><b>value</b>: Tekstualni opis anamneze pacijenta.</p></div>" }, "status": "final", "code": { "coding": [ { "system": "http://fhir.cezih.hr/specifikacije/CodeSystem/observations", "code": "15", "display": "Anamneza" } ] }, "subject": { "type": "Patient", "identifier": { "system": "http://fhir.cezih.hr/specifikacije/identifikatori/MBO", "value": "180223069" } }, "valueString": "Tekstualni opis anamneze pacijenta." } }, { "fullUrl": "urn:uuid:272c293d-48ec-4396-96b0-e80014c65317", "resource": { "resourceType": "Condition", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Condition</b></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"/><p><b>identifier</b>: id: cl3lndh7u000009l6hhzya349, id: 234121234</p><p><b>subject</b>: <a href=\"#urnuuidfc19e23e-0ea7-4c73-a550-54d15808fe15\">See above (urn:uuid:fc19e23e-0ea7-4c73-a550-54d15808fe15: Ivo Ivić)</a></p></div>" }, "identifier": [ { "system": "http://fhir.cezih.hr/specifikacije/identifikatori/identifikator-slucaja", "value": "cl3lndh7u000009l6hhzya349" }, { "system": "http://fhir.cezih.hr/specifikacije/identifikatori/lokalni-identifikator-slucaja", "value": "234121234" } ], "subject": { "reference": "urn:uuid:fc19e23e-0ea7-4c73-a550-54d15808fe15", "display": "Ivo Ivić" } } }, { "fullUrl": "urn:uuid:2d0a28e9-4009-4ee4-8224-7e1220d85507", "resource": { "resourceType": "CarePlan", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: CarePlan</b></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"/><p><b>status</b>: active</p><p><b>intent</b>: proposal</p><p><b>description</b>: Tekstualni opis svih preporučenih postupaka za daljnje liječenje pacijenta...</p><p><b>subject</b>: <span/></p></div>" }, "status": "active", "intent": "proposal", "description": "Tekstualni opis svih preporučenih postupaka za daljnje liječenje pacijenta...", "subject": { "type": "Patient", "identifier": { "system": "http://fhir.cezih.hr/specifikacije/identifikatori/MBO", "value": "180223069" } } } }, { "fullUrl": "urn:uuid:b908ceec-8db3-4859-b4c4-926980c655b4", "resource": { "resourceType": "Procedure", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Procedure</b></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"/><p><b>status</b>: completed</p><p><b>category</b>: Medicinski postupak <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-kategorija-postupka.html\">Kategorija postupka</a>#1)</span></p><p><b>code</b>: Sveobuhvatno gensko profiliranjetumorske DNK molekule metodom sekvenciranja nove generacije (NGS) - hybrid capture <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-DTP-sifrarnik.html\">DTP šifrarnik[0.1]</a>#LG216)</span></p><p><b>subject</b>: <span/></p><p><b>performed</b>: 2023-02-28</p><p><b>note</b>: Tekstualni opis postupka</p></div>" }, "status": "completed", "category": { "coding": [ { "system": "http://fhir.cezih.hr/specifikacije/CodeSystem/kategorija-postupka", "code": "1", "display": "Medicinski postupak" } ] }, "code": { "coding": [ { "system": "http://fhir.cezih.hr/specifikacije/CodeSystem/DTP-sifrarnik", "version": "0.1", "code": "LG216" } ] }, "subject": { "type": "Patient", "identifier": { "system": "http://fhir.cezih.hr/specifikacije/identifikatori/MBO", "value": "180223069" } }, "performedDateTime": "2023-02-28", "note": [ { "text": "Tekstualni opis postupka" } ] } }, { "fullUrl": "urn:uuid:55247671-086a-423a-8cb5-0557abbe9622", "resource": { "resourceType": "Procedure", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Procedure</b></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"/><p><b>status</b>: completed</p><p><b>statusReason</b>: Odbio pregled <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-odbijanje-intervencije.html\">Odbijanje intervencije hitne[0.1]</a>#1)</span></p><p><b>subject</b>: <span/></p><p><b>outcome</b>: Otpust <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-zavrsetak-hitnog-prijema.html\">Završetak hitnog prijema[0.1]</a>#1)</span></p></div>" }, "status": "completed", "statusReason": { "coding": [ { "system": "http://fhir.cezih.hr/specifikacije/CodeSystem/odbijanje-intervencije", "version": "0.1", "code": "1", "display": "Odbio pregled" } ] }, "subject": { "type": "Patient", "identifier": { "system": "http://fhir.cezih.hr/specifikacije/identifikatori/MBO", "value": "180223069" } }, "outcome": { "coding": [ { "system": "http://fhir.cezih.hr/specifikacije/CodeSystem/zavrsetak-hitnog-prijema", "version": "0.1", "code": "1", "display": "Otpust" } ] } } } ], "signature": { "type": [ { "system": "urn:iso-astm:E1762-95:2013", "code": "1.2.840.10065.1.12.1.1", "display": "Author's Signature" } ], "when": "02/28/2023 11:28:17", "who": { "reference": "urn:uuid:0b2d4e02-4096-439e-9a05-355f8d997e45", "display": "Doktor Davor" }, "data": "cG90cGlz" } }
Napomena o korištenju: poduzeti su svi napori kako bi se osiguralo da su primjeri točni i korisni, ali oni nisu normativni dio specifikacije.