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

Example Bundle: 醫療影像及報告 Bundle example

Document Details

Generated Narrative: Bundle 醫療影像及報告

Document Subject

Unable to resolve subject '->胖吉 綠 (official) Male, DoB: 1987-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))'

Document Content

Relevant diagnostic tests/laboratory data Narrative

Additional Resources Included in Document

Entry 1 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Composition/ImageComposition

Resource Composition:

Generated Narrative: Composition ImageComposition

identifier: https://dep.mohw.gov.tw//202212231005

status: Final

type: Radiology Study observation (narrative)

encounter: Encounter: status = finished; class = pre-admission (ActCode#PRENC); period = 2022-08-01 17:00:14-0500 --> 2022-08-01 18:00:14-0500; reasonCode = Primary malignant neoplasm of lung (disorder)

date: 2022-12-23 14:30:00+0800

author: Organization 台北榮民總醫院

title: 醫療影像及報告

Attesters

-ModeParty
*OfficialOrganization 台北榮民總醫院

Entry 2 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Patient/TWCorePatient

Resource Patient:

Generated Narrative: Patient TWCorePatient

胖吉 綠 (official) Male, DoB: 1987-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

Contact Detail
  • ph: 0912345678
  • 台北市北投區明德路365號(home)
Emergency Contact:
  • 大吉 綠 (Official) (Male)
  • 台北市北投區明德路365號(home)
  • ph: 0987654321

Entry 3 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Organization/TWCoreOrganization

Resource Organization:

Generated Narrative: Organization TWCoreOrganization

identifier: https://www.nhi.gov.tw/0601160016

active: true

type: Healthcare Provider

name: 台北榮民總醫院

Contacts

-TelecomAddress
*ph: 02-28712121石牌路二段201號 台北市 11219 台灣

Entry 4 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Practitioner/TWCorePractitioner

Resource Practitioner:

Generated Narrative: Practitioner TWCorePractitioner

identifier: Medical License number/tvgh001 (use: official, )

active: true

name: 大吉 連 (Official)

gender: Male

Entry 5 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Encounter/TWCoreEncounter

Resource Encounter:

Generated Narrative: Encounter TWCoreEncounter

Not done yet

Entry 6 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Condition/TWCoreCondition

Resource Condition:

Generated Narrative: Condition TWCoreCondition

clinicalStatus: Active

category: Encounter Diagnosis

code: 肺結核

subject: 胖吉 綠 (official) Male, DoB: 1987-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

Entry 7 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/ImagingStudy/ImagingStudyBase

Resource ImagingStudy:

Generated Narrative: ImagingStudy ImagingStudyBase

identifier: Study instancce UID/urn:oid:2.25.284733062255854756631429402605810248731 (use: official, ), Accession ID/2ffe0c20-50d8-49df-85f6-6452d1d201b9 (use: official, )

status: Available

subject: 胖吉 綠 (official) Male, DoB: 1987-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

started: 2024-01-01 11:01:20+0300

endpoint: Endpoint: status = active; connectionType = DICOM WADO-RS (Endpoint Connection Type#dicom-wado-rs); payloadType = ; payloadMimeType = application/dicom; address = http://localhost:8081/dicom-web

numberOfSeries: 1

numberOfInstances: 1

series

uid: 2.25.88017001449189502323411118737039844242

modality: Computed Tomography

numberOfInstances: 1

bodySite: No display for ImagingStudy.series.bodySite (concept: Pectoral region)

Instances

-UidSopClass
*2.25.284548087604447302186649612333159050027DICOM sopClass urn:oid:1.2.840.10008.5.1.4.1.1.1: Computed Radiography Image Storage

Entry 8 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Observation/ObservationImagingResult

Resource Observation:

Generated Narrative: Observation ObservationImagingResult

identifier: Accession ID/2ffe0c20-50d8-49df-85f6-6452d1d201b9 (use: official, )

status: Final

category: Imaging

code: Computerized Tomography (CT Scan) of Chest and Abdomen

subject: 胖吉 綠 (official) Male, DoB: 1987-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

effective: 2023-08-01 17:00:14-0500

performer: Practitioner 大吉 連 (official)

value: LUNGS AND PLEURA: Clear lungs. Normal pulmonary vascularity. No pleural effusion. No pneumothorax.

Entry 9 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/DiagnosticReport/ImageDiagnosticReport

Resource DiagnosticReport:

Computerized Tomography (CT Scan) of Chest and Abdomen (Radiology)

Subject胖吉 綠 (OFFICIAL) male, DoB: 1987-01-01 ( Social Beneficiary Identifier: A123456789)
Reported2022-08-30 10:35:32+0800
Identifier:Medical record number: 01260526

ImagingStudy Finding :

CodeValueWhen For
Computerized Tomography (CT Scan) of Chest and AbdomenLUNGS AND PLEURA: Clear lungs. Normal pulmonary vascularity. No pleural effusion. No pneumothorax.2022-08-30

ImagingStudy Impression :

No acute abnormality

Coded Conclusions :

  • Dull chest pain