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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🔗 "reference" : "Patient/pat-ds"
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{
🔗 "reference" : "Organization/org-ds"
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{
🔗 "reference" : "Organization/org-dis-ds"
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{
🔗 "reference" : "Practitioner/pra-ds"
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{
🔗 "reference" : "Practitioner/pra-dis-ds"
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"title" : "調劑單張",
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🔗 "reference" : "Organization/org-dis-ds"
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"section" : [
{
"code" : {
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{
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"text" : "Social history Narrative"
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{
🔗 "reference" : "Coverage/cov-ds"
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},
{
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],
"text" : "Vital signs, weight, height, head circumference, oxygen saturation and BMI panel"
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"entry" : [
{
🔗 "reference" : "Observation/obs-ds"
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]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29548-5"
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],
"text" : "Diagnosis Narrative"
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"entry" : [
{
🔗 "reference" : "Condition/con-ds"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29551-9"
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],
"text" : "Medication prescribed Narrative"
},
"entry" : [
{
🔗 "reference" : "Medication/med-01-ds"
},
{
🔗 "reference" : "MedicationRequest/med-req-01-ds"
},
{
🔗 "reference" : "MedicationDispense/med-dis-01-ds"
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{
🔗 "reference" : "ChargeItem/cha-ds"
}
]
},
{
"code" : {
"coding" : [
{
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"code" : "85647-6"
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],
"text" : "Signature of person collecting or coordinating collection of assessment information Provider"
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"entry" : [
{
🔗 "reference" : "Media/media-ds"
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}
]
}
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{
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Patient_pat-ds\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Patient pat-ds</b></p><a name=\"pat-ds\"> </a><a name=\"hcpat-ds\"> </a><a name=\"pat-ds-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"
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"gender" : "female",
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"text" : "新北市三重區集美街162號1樓"
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}
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Organization_org-dis-ds\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization org-dis-ds</b></p><a name=\"org-dis-ds\"> </a><a name=\"hcorg-dis-ds\"> </a><a name=\"org-dis-ds-en-US\"> </a><p><b>identifier</b>: Provider number/3531020884</p><p><b>name</b>: 洪文武藥局</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>"
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Practitioner_pra-ds\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Practitioner pra-ds</b></p><a name=\"pra-ds\"> </a><a name=\"hcpra-ds\"> </a><a name=\"pra-ds-en-US\"> </a><p><b>identifier</b>: <code>https://www.fda.gov.tw/</code>/A0429\u00a0(use:\u00a0official,\u00a0)</p><p><b>name</b>: 洪文武(Official)</p><p><b>telecom</b>: ph: 02-29765731(Work)</p></div>"
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"text" : "洪文武"
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Practitioner_pra-dis-ds\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Practitioner pra-dis-ds</b></p><a name=\"pra-dis-ds\"> </a><a name=\"hcpra-dis-ds\"> </a><a name=\"pra-dis-ds-en-US\"> </a><p><b>name</b>: 洪藥師(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 46255001}\">Pharmacist</span></td></tr></table></div>"
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"text" : "洪藥師"
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"display" : "Pharmacist"
}
],
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}
}
]
}
},
{
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Encounter_enc-ds\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Encounter enc-ds</b></p><a name=\"enc-ds\"> </a><a name=\"hcenc-ds\"> </a><a name=\"enc-ds-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:{https://nhird.nhri.edu.tw/file_data/func_type.html 01}\">家醫科</span></p><p><b>subject</b>: <a href=\"Patient-pat-ds.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" : {
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"display" : "西醫一般案件"
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{
"system" : "https://nhird.nhri.edu.tw/file_data/func_type.html",
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"display" : "家醫科"
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],
"text" : "家醫科"
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"subject" : {
🔗 "reference" : "Patient/pat-ds"
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"period" : {
"start" : "2023-02-23"
}
}
},
{
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"resource" : {
"resourceType" : "Condition",
"id" : "con-ds",
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🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/Condition-DS"
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"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Condition_con-ds\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Condition con-ds</b></p><a name=\"con-ds\"> </a><a name=\"hccon-ds\"> </a><a name=\"con-ds-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-ds.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>"
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{
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"code" : "problem-list-item",
"display" : "Problem List Item"
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"code" : {
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{
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"code" : "A00",
"display" : "霍亂"
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},
"subject" : {
🔗 "reference" : "Patient/pat-ds"
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"note" : [
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"text" : "001"
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},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Observation/obs-ds",
"resource" : {
"resourceType" : "Observation",
"id" : "obs-ds",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/Observation-DS-BodyWeight"
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},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Observation_obs-ds\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Observation obs-ds</b></p><a name=\"obs-ds\"> </a><a name=\"hcobs-ds\"> </a><a name=\"obs-ds-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-ds.html\">甄○康(official) Female, DoB: 1985-01-02 ( Medical record number: Z199999829\u00a0(use:\u00a0official,\u00a0))</a></p><p><b>encounter</b>: <a href=\"Encounter-enc-ds.html\">Encounter: status = finished; class = 西醫一般案件 (casetype#01); serviceType = 家醫科; period = 2023-02-23 --> (ongoing)</a></p><p><b>effective</b>: 2023-12-21</p><p><b>performer</b>: <a href=\"Practitioner-pra-dis-ds.html\">Practitioner 洪藥師(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",
"display" : "Vital Signs"
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]
}
],
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29463-7",
"display" : "Body weight"
}
]
},
"subject" : {
🔗 "reference" : "Patient/pat-ds"
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"encounter" : {
🔗 "reference" : "Encounter/enc-ds"
},
"effectiveDateTime" : "2023-12-21",
"performer" : [
{
🔗 "reference" : "Practitioner/pra-dis-ds"
}
],
"valueQuantity" : {
"value" : 50,
"unit" : "kg",
"system" : "http://unitsofmeasure.org",
"code" : "kg"
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}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Coverage/cov-ds",
"resource" : {
"resourceType" : "Coverage",
"id" : "cov-ds",
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},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Coverage_cov-ds\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Coverage cov-ds</b></p><a name=\"cov-ds\"> </a><a name=\"hccov-ds\"> </a><a name=\"cov-ds-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 4}\">普通疾病</span></p><p><b>beneficiary</b>: <a href=\"Patient-pat-ds.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-ds.html\">甄○康(official) Female, DoB: 1985-01-02 ( Medical record number: Z199999829\u00a0(use:\u00a0official,\u00a0))</a></p></div>"
},
"status" : "active",
"type" : {
"coding" : [
{
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"code" : "4",
"display" : "普通疾病"
}
]
},
"beneficiary" : {
🔗 "reference" : "Patient/pat-ds"
},
"payor" : [
{
🔗 "reference" : "Patient/pat-ds"
}
]
}
},
{
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"resourceType" : "ChargeItem",
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"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"ChargeItem_cha-ds\"> </a><p class=\"res-header-id\"><b>Generated Narrative: ChargeItem cha-ds</b></p><a name=\"cha-ds\"> </a><a name=\"hccha-ds\"> </a><a name=\"cha-ds-en-US\"> </a><p><b>status</b>: Billed</p><p><b>code</b>: <span title=\"Codes:{https://twcore.mohw.gov.tw 05221A}\">藥事服務代碼</span></p><p><b>subject</b>: <a href=\"Patient-pat-ds.html\">甄○康(official) Female, DoB: 1985-01-02 ( Medical record number: Z199999829\u00a0(use:\u00a0official,\u00a0))</a></p></div>"
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},
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🔗 "reference" : "Patient/pat-ds"
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{
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"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/Medication-DS"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Medication_med-01-ds\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Medication med-01-ds</b></p><a name=\"med-01-ds\"> </a><a name=\"hcmed-01-ds\"> </a><a name=\"med-01-ds-en-US\"> </a><p><b>identifier</b>: 1</p><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>"
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{
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}
],
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{
"system" : "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medication-nhi-tw",
"code" : "A000015421"
}
],
"text" : "YEN KUANG EYE DROPS"
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"form" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-orderableDrugForm",
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"system" : "http://unitsofmeasure.org",
"code" : "mg"
}
}
}
]
}
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{
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"resource" : {
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},
"extension" : [
{
"url" : "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/Extension-TotalDuration",
"valueQuantity" : {
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"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"
}
]
},
{
"coding" : [
{
"system" : "https://www.nhi.gov.tw/",
"code" : "0",
"display" : "自行調劑或檢驗（查）或物理治療"
}
]
}
],
"medicationReference" : {
🔗 "reference" : "Medication/med-01-ds"
},
"subject" : {
🔗 "reference" : "Patient/pat-ds"
},
"encounter" : {
🔗 "reference" : "Encounter/enc-ds"
},
"authoredOn" : "2024-01-12T00:00:00+08:00",
"insurance" : [
{
🔗 "reference" : "Coverage/cov-ds"
}
],
"note" : [
{
"text" : "A"
},
{
"text" : "否"
}
],
"dosageInstruction" : [
{
"method" : {
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{
"system" : "http://snomed.info/sct",
"code" : "419385000",
"display" : "Use"
}
]
}
}
],
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"start" : "2024-01-12T00:00:00+08:00",
"end" : "2024-01-19T00:00:00+08:00"
},
"numberOfRepeatsAllowed" : 1
}
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/MedicationDispense/med-dis-01-ds",
"resource" : {
"resourceType" : "MedicationDispense",
"id" : "med-dis-01-ds",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/MedicationDispense-DS"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"MedicationDispense_med-dis-01-ds\"> </a><p class=\"res-header-id\"><b>Generated Narrative: MedicationDispense med-dis-01-ds</b></p><a name=\"med-dis-01-ds\"> </a><a name=\"hcmed-dis-01-ds\"> </a><a name=\"med-dis-01-ds-en-US\"> </a><p><b>identifier</b>: 3, 7</p><p><b>status</b>: Preparation</p><p><b>medication</b>: <a href=\"Medication-med-01-ds.html\">Medication YEN KUANG EYE DROPS</a></p><p><b>subject</b>: <a href=\"Patient-pat-ds.html\">甄○康(official) Female, DoB: 1985-01-02 ( Medical record number: Z199999829\u00a0(use:\u00a0official,\u00a0))</a></p><p><b>quantity</b>: 6 顆</p><p><b>daysSupply</b>: 10 Day<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM coded = 'd')</span></p><p><b>note</b>: A, 否</p><blockquote><p><b>dosageInstruction</b></p></blockquote><h3>Substitutions</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>WasSubstituted</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>"
},
"identifier" : [
{
"value" : "3"
},
{
"value" : "7"
}
],
"status" : "preparation",
"medicationReference" : {
🔗 "reference" : "Medication/med-01-ds"
},
"subject" : {
🔗 "reference" : "Patient/pat-ds"
},
"quantity" : {
"value" : 6,
"unit" : "顆"
},
"daysSupply" : {
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"unit" : "Day",
"system" : "http://unitsofmeasure.org",
"code" : "d"
},
"note" : [
{
"text" : "A"
},
{
"text" : "否"
}
],
"dosageInstruction" : [
{
"timing" : {
"repeat" : {
"frequency" : 4
},
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-GTSAbbreviation",
"code" : "PM",
"display" : "PM"
}
]
}
},
"route" : {
"coding" : [
{
"system" : "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medication-path-tw",
"code" : "PO"
}
]
},
"doseAndRate" : [
{
"doseQuantity" : {
"value" : 1.0,
"unit" : "顆"
}
}
]
}
],
"substitution" : {
"wasSubstituted" : true,
"reason" : [
{
"text" : "不可替代時始需註明"
}
]
}
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Media/media-ds",
"resource" : {
"resourceType" : "Media",
"id" : "media-ds",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/Media-DS"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Media_media-ds\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Media media-ds</b></p><a name=\"media-ds\"> </a><a name=\"hcmedia-ds\"> </a><a name=\"media-ds-en-US\"> </a><p><b>status</b>: Completed</p><p><b>subject</b>: <a href=\"Patient-pat-ds.html\">甄○康(official) Female, DoB: 1985-01-02 ( Medical record number: Z199999829\u00a0(use:\u00a0official,\u00a0))</a></p><h3>Contents</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>ContentType</b></td><td><b>Data</b></td></tr><tr><td style=\"display: none\">*</td><td>image/jpeg</td><td><code>6aCY6Jel6ICF5pW45L2N57C956ug</code></td></tr></table></div>"
},
"status" : "completed",
"subject" : {
🔗 "reference" : "Patient/pat-ds"
},
"content" : {
"contentType" : "image/jpeg",
"data" : "6aCY6Jel6ICF5pW45L2N57C956ug"
}
}
}
]
}