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    <title>Recepta pielęgniarska</title>
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                <city>Warszawa</city>
                <streetName>Odkryta</streetName>
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                <unitID>12</unitID>
                <censusTract>TERYT SIMC: 987654</censusTract>
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            <patient>
                <name>
                    <given>Jan</given>
                    <given>Franciszek</given>
                    <family>Kowalski</family>
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                <name>Praktyka pielęgniarska Anna Wyszyńska</name>
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		                    <city>Warszawa</city>
		                    <streetName>Litewska</streetName>
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                    <title>Rp</title>
					<text>
						<paragraph ID="SPLY_1">
							<content ID="p1_nazwaWyrobu" styleCode="xPLbig">Accu-Chek Active</content>
							<content ID="p1_postacWyrobu">test paskowy</content>
							<content ID="p1_edytuj_postacWyrobu"></content>
						</paragraph>
						<paragraph>
							<content ID="p1_iloscWyrobu">2</content>
							<content ID="p1_krotnosc_opis">op. po</content>
							<content ID="p1_wielkoscOpakowania">50 szt.</content>
						</paragraph>
						<paragraph>
							<content ID="p1_edytuj_stosowanie_wartosc">D.S. Pomiar glukozy 2 x dziennie</content>
						</paragraph>
						<paragraph ID="ACT_1">
							<content ID="p1_odplatnosc_opis">Odpłatność</content>
							<content ID="p1_odplatnosc_wartosc" styleCode="Bold">100%</content>
						</paragraph>
					</text>
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                        <supply classCode="SPLY" moodCode="RQO">
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                            <effectiveTime value="20171022"/>
                            <quantity value="2"/>
                            <product>
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                                        <templateId root="2.16.840.1.113883.3.4424.13.10.4.73"/>
                                        <code code="4015630056316" codeSystem="1.3.160" codeSystemName="GS1"/>
                                        <name>Accu-Chek Active</name>
                                        <!-- <pharm:formCode code="xxxx" displayName="test paskowy" codeSystem="2.16.840.1.113883.3.4424.999.999.999"/> -->
                                        <pharm:asContent classCode="CONT">
                                            <pharm:containerPackagedMedicine classCode="CONT" determinerCode="INSTANCE">
                                                <pharm:code code="4015630056316" codeSystem="1.3.160" codeSystemName="GS1"/>
                                                <pharm:name>Paski testowe Accu Chek Active, 50 szt.</pharm:name>
                                                <pharm:capacityQuantity value="50"/>
                                            </pharm:containerPackagedMedicine>
                                        </pharm:asContent>
                                    </manufacturedMaterial>
                                </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="100%" codeSystem="2.16.840.1.113883.3.4424.11.1.1" displayName="pełnopłatne" />
                                                </qualifier>
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                                            <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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                            </entryRelationship>
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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">
							<content ID="p1_platnik_opis_1">Oddział NFZ</content>
							<content ID="p1_platnik_wartosc_1" styleCode="Bold">07</content>
						</paragraph>
						<paragraph>
							<content ID="p1_uprawnieniaDodatkowe_opis_1">Uprawnienia dodatkowe</content>
							<content ID="p1_uprawnieniaDodatkowe_wartosc_1"
								styleCode="Bold">IB</content>
							(
							<content ID="p1_dokumentUprawnien_wartosc_1">Nr leg.: 234/1992</content>
							)
						</paragraph>
					</text>
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                        <act classCode="ACT" moodCode="DEF">
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                            <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"/>
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                                        <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"/>
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                                    </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">
                                                <supply classCode="SPLY" moodCode="PRMS">
                                                    <id extension="aa3434-1" root="2.16.840.1.113883.3.4424.2.7.99999.2.3"/>
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                                            </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>
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        </structuredBody>
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</ClinicalDocument>
