電子病歷交換單張實作指引(EMR-IG)
0.1.0 - ci-build
This page is part of the 電子病歷交換單張實作指引(EMR-IG) (v0.1.0: Releases) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
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"timestamp" : "2024-02-19T14:30:00+01:00",
"entry" : [
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Composition/com",
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"resourceType" : "Composition",
"id" : "com",
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Composition_com\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Composition com</b></p><a name=\"com\"> </a><a name=\"hccom\"> </a><a name=\"com-en-US\"> </a><p><b>status</b>: Final</p><p><b>type</b>: <span title=\"Codes:{http://loinc.org 57833-6}\">Prescription for medication</span></p><p><b>encounter</b>: <a href=\"Encounter-enc.html\">Encounter: status = finished; class = 西醫一般案件 (casetype#01); serviceType = General surgery (qualifier value); period = 2023-02-23 --> (ongoing)</a></p><p><b>date</b>: 2024-02-19 14:30:00+0100</p><p><b>author</b>: </p><ul><li><a href=\"Organization-org.html\">Organization 洪文武診所</a></li><li><a href=\"Practitioner-pra.html\">Practitioner 洪文武(official)</a></li></ul><p><b>title</b>: 電子處方箋</p><p><b>custodian</b>: <a href=\"Organization-org.html\">Organization 洪文武診所</a></p></div>"
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"subject" : {
🔗 "reference" : "Patient/pat"
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"encounter" : {
🔗 "reference" : "Encounter/enc"
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"date" : "2024-02-19T14:30:00+01:00",
"author" : [
{
🔗 "reference" : "Organization/org"
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{
🔗 "reference" : "Practitioner/pra"
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],
"title" : "電子處方箋",
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🔗 "reference" : "Organization/org"
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"section" : [
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29762-2"
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],
"text" : "Social history Narrative"
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"entry" : [
{
🔗 "reference" : "Coverage/cov"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "85353-1"
}
],
"text" : "Vital signs, weight, height, head circumference, oxygen saturation and BMI panel"
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"entry" : [
{
🔗 "reference" : "Observation/obs"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29548-5"
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],
"text" : "Diagnosis Narrative"
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"entry" : [
{
🔗 "reference" : "Condition/con"
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]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29551-9"
}
],
"text" : "Medication prescribed Narrative"
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"entry" : [
{
🔗 "reference" : "Medication/med-01"
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{
🔗 "reference" : "MedicationRequest/med-req-01"
}
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}
]
}
},
{
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"resource" : {
"resourceType" : "Patient",
"id" : "pat",
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"text" : {
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Patient_pat\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Patient pat</b></p><a name=\"pat\"> </a><a name=\"hcpat\"> </a><a name=\"pat-en-US\"> </a><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">甄○康(official) Female, DoB: 1985-01-02 ( Medical record number: Z199999829\u00a0(use:\u00a0official,\u00a0))</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"年齡\"><a href=\"https://twcore.mohw.gov.tw/ig/twcore/0.2.0/StructureDefinition-person-age.html\">Person Age</a></td><td colspan=\"3\">39 a<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codea = 'a')</span></td></tr></table></div>"
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"identifier" : [
{
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],
"name" : [
{
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"text" : "甄○康"
}
],
"gender" : "female",
"birthDate" : "1985-01-02"
}
},
{
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"resource" : {
"resourceType" : "Organization",
"id" : "org",
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},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Organization_org\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization org</b></p><a name=\"org\"> </a><a name=\"hcorg\"> </a><a name=\"org-en-US\"> </a><p><b>identifier</b>: Provider number/3531020884</p><p><b>name</b>: 洪文武診所</p><p><b>telecom</b>: ph: 02-29765731(Work)</p><p><b>address</b>: 新北市三重區集美街162號1樓(work)</p></div>"
},
"identifier" : [
{
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],
"name" : "洪文武診所",
"telecom" : [
{
"system" : "phone",
"value" : "02-29765731",
"use" : "work"
}
],
"address" : [
{
"use" : "work",
"text" : "新北市三重區集美街162號1樓"
}
]
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Practitioner/pra",
"resource" : {
"resourceType" : "Practitioner",
"id" : "pra",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/Practitioner-EP"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Practitioner_pra\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Practitioner pra</b></p><a name=\"pra\"> </a><a name=\"hcpra\"> </a><a name=\"pra-en-US\"> </a><p><b>name</b>: 洪文武(Official)</p><p><b>telecom</b>: ph: 02-29765731(Work)</p><h3>Qualifications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Identifier</b></td><td><b>Code</b></td></tr><tr><td style=\"display: none\">*</td><td><code>https://www.mohw.gov.tw/</code>/A1*****8028\u00a0(use:\u00a0official,\u00a0)</td><td><span title=\"Codes:{http://snomed.info/sct 223366009}\">Healthcare professional</span></td></tr></table></div>"
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"name" : [
{
"use" : "official",
"text" : "洪文武"
}
],
"telecom" : [
{
"system" : "phone",
"value" : "02-29765731",
"use" : "work"
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],
"qualification" : [
{
"identifier" : [
{
"use" : "official",
"system" : "https://www.mohw.gov.tw/",
"value" : "A1*****8028"
}
],
"code" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "223366009"
}
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}
}
]
}
},
{
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"resource" : {
"resourceType" : "Encounter",
"id" : "enc",
"meta" : {
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🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/Encounter-EP"
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},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Encounter_enc\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Encounter enc</b></p><a name=\"enc\"> </a><a name=\"hcenc\"> </a><a name=\"enc-en-US\"> </a><p><b>status</b>: Finished</p><p><b>class</b>: casetype 01: 西醫一般案件</p><p><b>serviceType</b>: <span title=\"Codes:{http://snomed.info/sct 394609007}\">普通外科</span></p><p><b>subject</b>: <a href=\"Patient-pat.html\">甄○康(official) Female, DoB: 1985-01-02 ( Medical record number: Z199999829\u00a0(use:\u00a0official,\u00a0))</a></p><p><b>period</b>: 2023-02-23 --> (ongoing)</p></div>"
},
"status" : "finished",
"class" : {
"system" : "https://standard-interoperability-lab.com/fhir/CodeSystem/casetype",
"code" : "01",
"display" : "西醫一般案件"
},
"serviceType" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "394609007"
}
],
"text" : "普通外科"
},
"subject" : {
🔗 "reference" : "Patient/pat"
},
"period" : {
"start" : "2023-02-23"
}
}
},
{
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"resource" : {
"resourceType" : "Observation",
"id" : "obs",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/Observation-EP-BodyWeight"
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},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Observation_obs\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Observation obs</b></p><a name=\"obs\"> </a><a name=\"hcobs\"> </a><a name=\"obs-en-US\"> </a><p><b>status</b>: Final</p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/observation-category vital-signs}\">Vital Signs</span></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 29463-7}\">Body weight</span></p><p><b>subject</b>: <a href=\"Patient-pat.html\">甄○康(official) Female, DoB: 1985-01-02 ( Medical record number: Z199999829\u00a0(use:\u00a0official,\u00a0))</a></p><p><b>effective</b>: 2023-12-21</p><p><b>performer</b>: <a href=\"Practitioner-pra.html\">Practitioner 洪文武(official)</a></p><p><b>value</b>: 50 kg<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codekg = 'kg')</span></p></div>"
},
"status" : "final",
"category" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/observation-category",
"code" : "vital-signs",
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}
]
}
],
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29463-7",
"display" : "Body weight"
}
]
},
"subject" : {
🔗 "reference" : "Patient/pat"
},
"effectiveDateTime" : "2023-12-21",
"performer" : [
{
🔗 "reference" : "Practitioner/pra"
}
],
"valueQuantity" : {
"value" : 50,
"unit" : "kg",
"system" : "http://unitsofmeasure.org",
"code" : "kg"
}
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Condition/con",
"resource" : {
"resourceType" : "Condition",
"id" : "con",
"meta" : {
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},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Condition_con\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Condition con</b></p><a name=\"con\"> </a><a name=\"hccon\"> </a><a name=\"con-en-US\"> </a><p><b>clinicalStatus</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/condition-clinical active}\">Active</span></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/condition-category problem-list-item}\">Problem List Item</span></p><p><b>code</b>: <span title=\"Codes:{https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2021-tw A00}\">霍亂</span></p><p><b>subject</b>: <a href=\"Patient-pat.html\">甄○康(official) Female, DoB: 1985-01-02 ( Medical record number: Z199999829\u00a0(use:\u00a0official,\u00a0))</a></p><p><b>note</b>: 001</p></div>"
},
"clinicalStatus" : {
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"code" : "active",
"display" : "Active"
}
]
},
"category" : [
{
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{
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"code" : "problem-list-item",
"display" : "Problem List Item"
}
]
}
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{
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"code" : "A00",
"display" : "霍亂"
}
]
},
"subject" : {
🔗 "reference" : "Patient/pat"
},
"note" : [
{
"text" : "001"
}
]
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Coverage/cov",
"resource" : {
"resourceType" : "Coverage",
"id" : "cov",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/Coverage-EMR"
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},
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"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Coverage_cov\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Coverage cov</b></p><a name=\"cov\"> </a><a name=\"hccov\"> </a><a name=\"cov-en-US\"> </a><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{https://twcore.mohw.gov.tw/ig/emr/CodeSystem/paymentcategory 1}\">職業傷害</span></p><p><b>beneficiary</b>: <a href=\"Patient-pat.html\">甄○康(official) Female, DoB: 1985-01-02 ( Medical record number: Z199999829\u00a0(use:\u00a0official,\u00a0))</a></p><p><b>payor</b>: <a href=\"Patient-pat.html\">甄○康(official) Female, DoB: 1985-01-02 ( Medical record number: Z199999829\u00a0(use:\u00a0official,\u00a0))</a></p></div>"
},
"status" : "active",
"type" : {
"coding" : [
{
"system" : "https://twcore.mohw.gov.tw/ig/emr/CodeSystem/paymentcategory",
"code" : "1",
"display" : "職業傷害"
}
]
},
"beneficiary" : {
🔗 "reference" : "Patient/pat"
},
"payor" : [
{
🔗 "reference" : "Patient/pat"
}
]
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Medication/med-01",
"resource" : {
"resourceType" : "Medication",
"id" : "med-01",
"meta" : {
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🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/Medication-EP"
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},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Medication_med-01\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Medication med-01</b></p><a name=\"med-01\"> </a><a name=\"hcmed-01\"> </a><a name=\"med-01-en-US\"> </a><p><b>code</b>: <span title=\"Codes:{https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medication-nhi-tw A000015421}\">YEN KUANG EYE DROPS</span></p><p><b>form</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-orderableDrugForm TAB}\">TAB</span></p><h3>Ingredients</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Item[x]</b></td><td><b>Strength</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:\">Alemtuzamab (substance)</span></td><td>250 mg<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codemg = 'mg')</span>/250 mg<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codemg = 'mg')</span></td></tr></table></div>"
},
"code" : {
"coding" : [
{
"system" : "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medication-nhi-tw",
"code" : "A000015421"
}
],
"text" : "YEN KUANG EYE DROPS"
},
"form" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-orderableDrugForm",
"code" : "TAB"
}
],
"text" : "TAB"
},
"ingredient" : [
{
"itemCodeableConcept" : {
"coding" : [
{
"display" : "Alemtuzamab (substance)"
}
]
},
"strength" : {
"numerator" : {
"value" : 250,
"system" : "http://unitsofmeasure.org",
"code" : "mg"
},
"denominator" : {
"value" : 250,
"system" : "http://unitsofmeasure.org",
"code" : "mg"
}
}
}
]
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/MedicationRequest/med-req-01",
"resource" : {
"resourceType" : "MedicationRequest",
"id" : "med-req-01",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/MedicationRequest-EP"
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},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"MedicationRequest_med-req-01\"> </a><p class=\"res-header-id\"><b>Generated Narrative: MedicationRequest med-req-01</b></p><a name=\"med-req-01\"> </a><a name=\"hcmed-req-01\"> </a><a name=\"med-req-01-en-US\"> </a><p><b>identifier</b>: <code>http://www.moi.gov.tw/</code>/Med000001, 7</p><p><b>status</b>: Active</p><p><b>intent</b>: Order</p><p><b>category</b>: <span title=\"Codes:{https://twcore.mohw.gov.tw/ig/emr/CodeSystem/prescription A}\">一般處方箋：處方用藥，一次給予7日(含)以下之用藥量</span></p><p><b>medication</b>: <a href=\"Medication-med-01.html\">Medication YEN KUANG EYE DROPS</a></p><p><b>subject</b>: <a href=\"Patient-pat.html\">甄○康(official) Female, DoB: 1985-01-02 ( Medical record number: Z199999829\u00a0(use:\u00a0official,\u00a0))</a></p><p><b>insurance</b>: <a href=\"Coverage-cov.html\">Coverage: status = active; type = 職業傷害</a></p><p><b>note</b>: A, 否</p><blockquote><p><b>dosageInstruction</b></p></blockquote><blockquote><p><b>dispenseRequest</b></p><p><b>validityPeriod</b>: 2024-01-12 00:00:00+0800 --> 2024-01-19 00:00:00+0800</p><p><b>numberOfRepeatsAllowed</b>: 1</p><p><b>quantity</b>: 12 顆</p><h3>ExpectedSupplyDurations</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td></tr><tr><td style=\"display: none\">*</td><td>3</td></tr></table></blockquote><h3>Substitutions</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Allowed[x]</b></td><td><b>Reason</b></td></tr><tr><td style=\"display: none\">*</td><td>true</td><td><span title=\"Codes:\">不可替代時始需註明</span></td></tr></table></div>"
},
"extension" : [
{
"url" : "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/Extension-TotalDuration",
"valueQuantity" : {
"value" : 7,
"unit" : "days"
}
}
],
"identifier" : [
{
"system" : "http://www.moi.gov.tw/",
"value" : "Med000001"
},
{
"value" : "7"
}
],
"status" : "active",
"intent" : "order",
"category" : [
{
"coding" : [
{
"system" : "https://twcore.mohw.gov.tw/ig/emr/CodeSystem/prescription",
"code" : "A"
}
]
}
],
"medicationReference" : {
🔗 "reference" : "Medication/med-01"
},
"subject" : {
🔗 "reference" : "Patient/pat"
},
"insurance" : [
{
🔗 "reference" : "Coverage/cov"
}
],
"note" : [
{
"text" : "A"
},
{
"text" : "否"
}
],
"dosageInstruction" : [
{
"timing" : {
"repeat" : {
"frequency" : 4
}
},
"route" : {
"coding" : [
{
"system" : "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medication-path-tw",
"code" : "PO"
}
]
},
"doseAndRate" : [
{
"doseQuantity" : {
"value" : 1.0,
"unit" : "顆"
}
}
]
}
],
"dispenseRequest" : {
"validityPeriod" : {
"start" : "2024-01-12T00:00:00+08:00",
"end" : "2024-01-19T00:00:00+08:00"
},
"numberOfRepeatsAllowed" : 1,
"quantity" : {
"value" : 12,
"unit" : "顆",
"system" : "http://unitsofmeasure.org"
},
"expectedSupplyDuration" : {
"value" : 3
}
},
"substitution" : {
"allowedBoolean" : true,
"reason" : {
"text" : "不可替代時始需註明"
}
}
}
}
]
}