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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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Patient_TWCorePatient\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Patient TWCorePatient</b></p><a name=\"TWCorePatient\"> </a><a name=\"hcTWCorePatient\"> </a><a name=\"TWCorePatient-en-US\"> </a><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">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\u00a0(use:\u00a0official,\u00a0))</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"Ways to contact the Patient\">Contact Detail</td><td colspan=\"3\"><ul><li>ph: 0912345678</li><li>台北市北投區明德路365號(home)</li></ul></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Nominated Contact: Emergency Contact\">Emergency Contact:</td><td colspan=\"3\"><ul><li>大吉 綠 (Official) (Male)</li><li>台北市北投區明德路365號(home)</li><li>ph: 0987654321</li></ul></td></tr></table></div>"
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Organization_TWCoreOrganization\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization TWCoreOrganization</b></p><a name=\"TWCoreOrganization\"> </a><a name=\"hcTWCoreOrganization\"> </a><a name=\"TWCoreOrganization-en-US\"> </a><p><b>identifier</b>: <code>https://www.nhi.gov.tw</code>/0601160016</p><p><b>active</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/organization-type prov}\">Healthcare Provider</span></p><p><b>name</b>: 台北榮民總醫院</p><p><b>telecom</b>: ph: 02-28712121</p><p><b>address</b>: 石牌路二段201號 台北市 11219 台灣 </p></div>"
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Encounter_TWCoreEncounter\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Encounter TWCoreEncounter</b></p><a name=\"TWCoreEncounter\"> </a><a name=\"hcTWCoreEncounter\"> </a><a name=\"TWCoreEncounter-en-US\"> </a><p><b>status</b>: Finished</p><p><b>class</b>: <a href=\"http://terminology.hl7.org/6.0.2/CodeSystem-v3-ActCode.html#v3-ActCode-PRENC\">ActCode</a> PRENC: pre-admission</p><p><b>subject</b>: <a href=\"Patient-TWCorePatient.html\">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\u00a0(use:\u00a0official,\u00a0))</a></p><h3>Participants</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Period</b></td><td><b>Individual</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ParticipationType PPRF}\">primary performer</span></td><td>2022-08-01 17:00:14-0500 --> 2022-08-01 18:00:14-0500</td><td><a href=\"Practitioner-TWCorePractitioner.html\">Practitioner 大吉 連 (official)</a></td></tr></table><p><b>period</b>: 2022-08-01 17:00:14-0500 --> 2022-08-01 18:00:14-0500</p><p><b>reasonCode</b>: <span title=\"Codes:{http://snomed.info/sct 93880001}\">Primary malignant neoplasm of lung (disorder)</span></p></div>"
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{
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{
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"ImagingStudy_ImagingStudyBase\"> </a><p class=\"res-header-id\"><b>Generated Narrative: ImagingStudy ImagingStudyBase</b></p><a name=\"ImagingStudyBase\"> </a><a name=\"hcImagingStudyBase\"> </a><a name=\"ImagingStudyBase-en-US\"> </a><p><b>identifier</b>: Study instancce UID/urn:oid:2.25.284733062255854756631429402605810248731\u00a0(use:\u00a0official,\u00a0), Accession ID/2ffe0c20-50d8-49df-85f6-6452d1d201b9\u00a0(use:\u00a0official,\u00a0)</p><p><b>status</b>: Available</p><p><b>subject</b>: <a href=\"Patient-TWCorePatient.html\">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\u00a0(use:\u00a0official,\u00a0))</a></p><p><b>started</b>: 2024-01-01 11:01:20+0300</p><p><b>endpoint</b>: <a href=\"Endpoint-MitwEndpoint.html\">Endpoint: status = active; connectionType = DICOM WADO-RS (Endpoint Connection Type#dicom-wado-rs); payloadType = ; payloadMimeType = application/dicom; address = http://localhost:8081/dicom-web</a></p><p><b>numberOfSeries</b>: 1</p><p><b>numberOfInstances</b>: 1</p><p><b>procedureReference</b>: <a href=\"Procedure-TWCoreProcedure.html\">Procedure 胸部及腹部電腦斷層掃描</a></p><p><b>procedureCode</b>: <span title=\"Codes:{https://twcore.mohw.gov.tw/ig/emr/CodeSystem/ICD-10-procedurecode BW24ZZZ}\">Computerized Tomography (CT Scan) of Chest and Abdomen</span></p><blockquote><p><b>series</b></p><p><b>uid</b>: 2.25.88017001449189502323411118737039844242</p><p><b>modality</b>: <a href=\"CodeSystem-AcquisitionModality.html#AcquisitionModality-CT\">Acquisition Modality</a> CT: Computed Tomography</p><p><b>numberOfInstances</b>: 1</p><p><b>bodySite</b>: <a href=\"http://snomed.info/id/251007\">SNOMED CT (all versions)</a> 251007: Pectoral region</p><h3>Instances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Uid</b></td><td><b>SopClass</b></td></tr><tr><td style=\"display: none\">*</td><td>2.25.284548087604447302186649612333159050027</td><td><a href=\"CodeSystem-DicomsopClass.html#DicomsopClass-urn.58oid.581.462.46840.4610008.465.461.464.461.461.461\">DICOM sopClass</a> urn:oid:1.2.840.10008.5.1.4.1.1.1: Computed Radiography Image Storage</td></tr></table></blockquote></div>"
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{
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"value" : "2ffe0c20-50d8-49df-85f6-6452d1d201b9"
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"status" : "available",
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🔗 "reference" : "Patient/TWCorePatient"
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"started" : "2024-01-01T11:01:20+03:00",
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{
🔗 "reference" : "Endpoint/MitwEndpoint"
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"bodySite" : {
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{
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Observation_ObservationImagingResult\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Observation ObservationImagingResult</b></p><a name=\"ObservationImagingResult\"> </a><a name=\"hcObservationImagingResult\"> </a><a name=\"ObservationImagingResult-en-US\"> </a><p><b>identifier</b>: Accession ID/2ffe0c20-50d8-49df-85f6-6452d1d201b9\u00a0(use:\u00a0official,\u00a0)</p><p><b>status</b>: Final</p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/observation-category imaging}\">Imaging</span></p><p><b>code</b>: <span title=\"Codes:{https://twcore.mohw.gov.tw/ig/emr/CodeSystem/ICD-10-procedurecode BW24ZZZ}\">Computerized Tomography (CT Scan) of Chest and Abdomen</span></p><p><b>subject</b>: <a href=\"Patient-TWCorePatient.html\">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\u00a0(use:\u00a0official,\u00a0))</a></p><p><b>effective</b>: 2023-08-01 17:00:14-0500</p><p><b>performer</b>: <a href=\"Practitioner-TWCorePractitioner.html\">Practitioner 大吉 連 (official)</a></p><p><b>value</b>: LUNGS AND PLEURA: Clear lungs. Normal pulmonary vascularity. No pleural effusion. No pneumothorax.</p></div>"
},
"identifier" : [
{
"use" : "official",
"type" : {
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"code" : "ACSN",
"display" : "Accession ID"
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},
"system" : "http://www.moi.gov.tw/",
"value" : "2ffe0c20-50d8-49df-85f6-6452d1d201b9"
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],
"status" : "final",
"category" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/observation-category",
"code" : "imaging",
"display" : "Imaging"
}
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],
"code" : {
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{
"system" : "https://twcore.mohw.gov.tw/ig/emr/CodeSystem/ICD-10-procedurecode",
"code" : "BW24ZZZ",
"display" : "Computerized Tomography (CT Scan) of Chest and Abdomen"
}
]
},
"subject" : {
🔗 "reference" : "Patient/TWCorePatient"
},
"effectiveDateTime" : "2023-08-01T17:00:14-05:00",
"performer" : [
{
🔗 "reference" : "Practitioner/TWCorePractitioner"
}
],
"valueString" : "LUNGS AND PLEURA: Clear lungs. Normal pulmonary vascularity. No pleural effusion. No pneumothorax."
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/DiagnosticReport/ImageDiagnosticReport",
"resource" : {
"resourceType" : "DiagnosticReport",
"id" : "ImageDiagnosticReport",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/DiagnosticReport-Image"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h2><span title=\"Codes: {https://fhir.tw/fhir/ig/lungcancer/CodeSystem/ICD-10-procedurecode BW24ZZZ}\">Computerized Tomography (CT Scan) of Chest and Abdomen</span> (<span title=\"Codes: {http://loinc.org LP29684-5}\">Radiology</span>)</h2><table class=\"grid\"><tr><td>Subject</td><td><b>胖吉 綠 (OFFICIAL)</b> male, DoB: 1987-01-01 ( Social Beneficiary Identifier: A123456789)</td></tr><tr><td>Reported</td><td>2022-08-30 10:35:32+0800</td></tr><tr><td>Identifier:</td><td>Medical record number: 01260526</td></tr></table><p><b>ImagingStudy Finding :</b></p><table class=\"grid\"><tr><td><b>Code</b></td><td><b>Value</b></td><td><b>When For</b></td></tr><tr><td><a href=\"Observation-ObservationImagingResult.html\"><span title=\"Codes: {https://fhir.tw/fhir/ig/lungcancer/CodeSystem/ICD-10-procedurecode BW24ZZZ}\">Computerized Tomography (CT Scan) of Chest and Abdomen</span></a></td><td>LUNGS AND PLEURA: Clear lungs. Normal pulmonary vascularity. No pleural effusion. No pneumothorax.</td><td>2022-08-30</td></tr></table><p><b>ImagingStudy Impression :</b></p><p>No acute abnormality</p><p><b>Coded Conclusions :</b></p><ul><li><span title=\"Codes: {http://snomed.info/sct 3368006}\">Dull chest pain</span></li></ul></div>"
},
"identifier" : [
{
"system" : "https://www.vghtpe.gov.tw/",
"value" : "123456"
}
],
"status" : "final",
"category" : [
{
"coding" : [
{
"system" : "http://loinc.org",
"code" : "LP29684-5",
"display" : "Radiology"
}
]
}
],
"code" : {
"coding" : [
{
"system" : "https://twcore.mohw.gov.tw/ig/emr/CodeSystem/ICD-10-procedurecode",
"code" : "BW24ZZZ",
"display" : "Computerized Tomography (CT Scan) of Chest and Abdomen"
}
]
},
"subject" : {
🔗 "reference" : "Patient/TWCorePatient"
},
"encounter" : {
🔗 "reference" : "Encounter/TWCoreEncounter"
},
"effectiveDateTime" : "2023-08-01T17:00:14-05:00",
"issued" : "2022-08-30T14:35:32.631Z",
"performer" : [
{
🔗 "reference" : "Practitioner/TWCorePractitioner"
}
],
"resultsInterpreter" : [
{
🔗 "reference" : "Practitioner/TWCorePractitioner"
}
],
"result" : [
{
🔗 "reference" : "Observation/ObservationImagingResult"
}
],
"imagingStudy" : [
{
🔗 "reference" : "ImagingStudy/ImagingStudyBase"
}
],
"conclusion" : "No acute abnormality",
"conclusionCode" : [
{
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "3368006",
"display" : "Dull chest pain"
}
]
}
]
}
}
]
}