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: 門診病歷 Bundle example

Document Details

Generated Narrative: Bundle 門診病歷

Document Subject

Unable to resolve subject '->測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))'

Document Content

門診病歷中的病人基本資料_實驗室檢查紀錄

門診病歷中的病人基本資料_重大傷病

門診病歷中的病人基本資料_過敏史

門診病歷中的病人基本資料_職業

門診病歷中的病人基本資料_就醫身分別

門診病歷中的診斷

門診病歷中的診斷病情摘要_主、客觀描述與評估

門診病歷中的處置項目

門診病歷中的處方內容

門診病歷中的家族圖譜

門診病歷中的門診圖像

Additional Resources Included in Document

Entry 1 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Composition/PMR-Com24

Resource Composition:

Generated Narrative: Composition PMR-Com24

status: Final

type: 門診病歷

encounter: Encounter: identifier = https://www.vghtpe.gov.tw/Index.action#Encounter唯一碼,http://loinc.org#LOINC#8653-8; status = finished; class = ambulatory (v3-ActEncounterCode#AMB); serviceType = General surgery (qualifier value); period = 2022-07-08 12:12:00+0000 --> (ongoing)

date: 2023-01-04 13:01:56+0800

author: Organization 國立臺灣大學醫學院附設醫院

title: 門診病歷

Entry 2 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Organization/PMR-Org1

Resource Organization:

Generated Narrative: Organization PMR-Org1

identifier: 0401180014

name: 國立臺灣大學醫學院附設醫院

Entry 3 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Patient/PMR-Pat2

Resource Patient:

Generated Narrative: Patient PMR-Pat2

測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

Active:true
Other Id:Medical record number/123456

Entry 4 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Observation/PMR-Obs3

Resource Observation:

Generated Narrative: Observation PMR-Obs3

status: Final

code: 實驗室檢查紀錄

subject: 測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

effective: 2023-10-01 16:52:00+0800

performer: Practitioner 賴一施

component

code: Rh

value: Rh positive

component

code: ABO group

value: B

Entry 5 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Condition/PMR-Con4

Resource Condition:

Generated Narrative: Condition PMR-Con4

clinicalStatus: Active

category: 重大傷病

code: 肺結核

subject: 測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

note: 再生不良性貧血、過敏性血管炎

Entry 6 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/AllergyIntolerance/PMR-All5

Resource AllergyIntolerance:

Generated Narrative: AllergyIntolerance PMR-All5

clinicalStatus: Inactive

verificationStatus: Unconfirmed

code: 無

patient: 測試員 Male, DoB: 1997-01-01 ( 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/Observation/PMR-Obs6

Resource Observation:

Generated Narrative: Observation PMR-Obs6

status: Final

code: Usual occupation

subject: 測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

effective: 2023-10-01 16:52:00+0800

performer: Practitioner 賴一施

value: 服務業/一般職員

Entry 8 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Coverage/PMR-Cov7

Resource Coverage:

Generated Narrative: Coverage PMR-Cov7

status: Active

type: 職業傷害

beneficiary: 測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

Entry 9 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Encounter/PMR-Enc8

Resource Encounter:

Generated Narrative: Encounter PMR-Enc8

Not done yet

Entry 10 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Condition/PMR-Con9

Resource Condition:

Generated Narrative: Condition PMR-Con9

clinicalStatus: 診斷

category: 診斷

code: 結核病(Tuberculosis)

subject: 測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

note: 未確認流感病毒所致流行性感冒併明示類型肺炎

Entry 11 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/ClinicalImpression/PMR-Cli10

Resource ClinicalImpression:

Generated Narrative: ClinicalImpression PMR-Cli10

status: Completed

subject: 測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

note: stable now and no complaint，report normal home BP；ever increased BP noted for weeks，no DOE，no chest pain，no syncope；no PND，no orthopnea

Entry 12 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/ClinicalImpression/PMR-Cli11

Resource ClinicalImpression:

Generated Narrative: ClinicalImpression PMR-Cli11

status: Completed

subject: 測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

note: BP：148/70 mmHg，HR：66/min,PE：pale conjunctiva-，icteric sclera-； JVE- ， carotid bruits-，goiter-；clear bs，no rales，no wheezing；RHB，soft SM，Peripheral pulses：++，pitting edema-Previous, CXR：no cardiomegaly

Entry 13 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/ClinicalImpression/PMR-Cli12

Resource ClinicalImpression:

Generated Narrative: ClinicalImpression PMR-Cli12

status: Completed

subject: 測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

note: HCVD

Entry 14 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Procedure/PMR-Pro13

Resource Procedure:

Generated Narrative: Procedure PMR-Pro13

identifier: https://www.vghtpe.gov.tw/Index.action/1

status: Completed

code: Procedure

subject: 測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

bodySite: 妊娠子宮

followUp: 一次性處置, 1, 次

note: 持續追蹤

Entry 15 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/MedicationRequest/PMR-MedReq14

Resource MedicationRequest:

Generated Narrative: MedicationRequest PMR-MedReq14

identifier: https://www.vghtpe.gov.tw/Index.action/項次id

status: Completed

intent: Order

category: Medication prescribed

subject: 測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

dosageInstruction

dispenseRequest

validityPeriod: 2020-07-01 --> 2020-07-31

numberOfRepeatsAllowed: 1

quantity: 31 TAB (Details: Orderable Drug Form codeTAB = 'Tablet')

ExpectedSupplyDurations

-ValueUnitSystemCode
*31dayshttp://unitsofmeasure.orgd

Entry 16 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Medication/PMR-Med15

Resource Medication:

Generated Narrative: Medication PMR-Med15

code: 阿立批挫

Entry 17 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Media/PMR-Media16

Resource DocumentReference:

Generated Narrative: DocumentReference PMR-Media16

Entry 18 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Media/PMR-Media17

Resource DocumentReference:

Generated Narrative: DocumentReference PMR-Media17

Entry 19 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Practitioner/PMR-Pra18

Resource Practitioner:

Generated Narrative: Practitioner PMR-Pra18

identifier: https://www.vghtpe.gov.tw/Index.action/123

name: 賴一施