HL7 Czech PS Implementation Guide
0.0.1 - ci-build CZ

HL7 Czech PS Implementation Guide, published by HL7 Czech Republic. This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7-cz/ps/ and changes regularly. See the Directory of published versions

: Pacientský souhrn - L3 composition

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      <div xmlns="http://www.w3.org/1999/xhtml">1. Fibrilace síní<br/>2. Hypertenze<br/>3. Astma bronchiale</div>
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      <div xmlns="http://www.w3.org/1999/xhtml"><ul><li>Penicilin – anafylaktická reakce (2018)</li><li>Latex – kontaktní dermatitida</li><li>Ořechy – kopřivka, otok rtů (dětský věk)</li></ul></div>
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      <div xmlns="http://www.w3.org/1999/xhtml">Pacient užívá následující medikaci: Warfarin 5 mg denně, Metoprolol 50 mg denně, Salbutamol inhalátor podle potřeby.</div>
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      <div xmlns="http://www.w3.org/1999/xhtml">Pacient prodělal v minulosti několik kardiologických výkonů, včetně implantace kardiostimulátoru a katetrizačního vyšetření koronárních tepen.</div>
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      <div xmlns="http://www.w3.org/1999/xhtml">Pacient má v anamnéze implantaci kardiostimulátoru pro fibrilaci síní.</div>
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      <div xmlns="http://www.w3.org/1999/xhtml">Pacient si nepřeje být resuscitován.</div>
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      <div xmlns="http://www.w3.org/1999/xhtml">Pacient na dlouhodobé antikoagulační léčbě.</div>
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    <title value="Příběh pacienta"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10164-2"/>
      </coding>
    </code>
    <text>
      <status value="additional"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><p>Pacientka je aktivní a preferuje ambulantní vedení péče. Důraz klade na zachování soběstačnosti a mobility. Je informovaná o dlouhodobé antikoagulační léčbě a spolupracuje na monitoraci INR(srážlivost).</p></div>
    </text>
  </section>
  <section>
    <title value="Plán péče"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="18776-5"/>
      </coding>
    </code>
    <text>
      <status value="additional"/>
      <div xmlns="http://www.w3.org/1999/xhtml">Plán péče zaměřený na dlouhodobé vedení pacientky s fibrilací síní, včetně antikoagulační léčby warfarinem, monitorování INR a prevence komplikací.</div>
    </text>
    <entry>
      <reference value="urn:uuid:9c913d06-84fe-4d35-b35b-8b0c7965f536"/>
    </entry>
  </section>
  <section>
    <title value="Sociální anamnéza"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="29762-2"/>
      </coding>
    </code>
    <text>
      <status value="additional"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Social History</b></p><ul><li><b>Alcohol consumption:</b> Occasional use (approximately 1–2 beers per week). Recorded on 01.03.2025 by general practitioner.</li><li><b>Tobacco use:</b> 0.5 pack/day. Patient reported smoking from 15.04.2017 to 15.04.2020. Entered by general practitioner.</li></ul></div>
    </text>
    <entry>
      <reference value="urn:uuid:23e3b557-ba77-4538-bac5-cc747c0077b1"/>
    </entry>
    <entry>
      <reference value="urn:uuid:2030d019-7d45-4a8c-8190-3b28cfe8f29f"/>
    </entry>
  </section>
  <section>
    <title value="Vital signs"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="8716-3"/>
      </coding>
    </code>
    <text>
      <status value="additional"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Vital signs</b> (2024-03-28)</p><ul><li><b>Blood pressure:</b> 120/80 mmHg</li><li><b>Body height:</b> 175 cm</li><li><b>Body weight:</b> 70 kg</li><li><b>Body mass index (BMI):</b> 22.5 kg/m2</li><li><b>Waist circumference:</b> 85 cm</li><li><b>Head circumference:</b> 50 cm</li></ul><p>All measurements recorded by Practitioner-2.</p></div>
    </text>
    <entry>
      <reference value="urn:uuid:7cf304de-5ae3-4621-8531-9c8f0b2d4e3a"/>
    </entry>
    <entry>
      <reference value="urn:uuid:8d2aea77-f576-4d0f-9508-537359aa44d6"/>
    </entry>
    <entry>
      <reference value="urn:uuid:4ba395b7-be9e-4bed-bef7-1c8f0b2d4e3a"/>
    </entry>
    <entry>
      <reference value="urn:uuid:5c363e2d-c4e1-436d-bad7-0b3f8c6a9f1d"/>
    </entry>
    <entry>
      <reference value="urn:uuid:6bec5d97-a17e-4015-8fce-7b1c0c3a2f4b"/>
    </entry>
    <entry>
      <reference value="urn:uuid:5c2ddf62-9785-493f-80c6-8b0d1e3a4b2c"/>
    </entry>
  </section>
  <section>
    <title value="Cestovatelská anamnéza"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10182-4"/>
      </coding>
    </code>
    <text>
      <status value="additional"/>
      <div xmlns="http://www.w3.org/1999/xhtml">Pacient navštívil Madagaskar během posledních 30 dnů.</div>
    </text>
    <entry>
      <reference value="urn:uuid:506936ca-99d2-47dc-a365-e10ec008c89a"/>
    </entry>
  </section>
  <section>
    <title value="Historie zdravotních problémů"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="11348-0"/>
        <display value="History of Past illness note"/>
      </coding>
    </code>
    <text>
      <status value="additional"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><ul><li>Hypertenze</li><li>Fibrilace síní</li><li>Astma bronchiale</li></ul></div>
    </text>
    <entry>
      <reference value="urn:uuid:0e95d603-0fb7-475e-aab3-3bf30b281cfd"/>
    </entry>
    <entry>
      <reference value="urn:uuid:8e620d4e-74fd-486b-ba57-0f0895f24f26"/>
    </entry>
    <entry>
      <reference value="urn:uuid:3881d35f-3f28-4d0f-b850-5d356f12f008"/>
    </entry>
  </section>
</Composition>