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
{
"resourceType" : "Bundle",
"id" : "example-PMR",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRBundle"
]
},
"identifier" : {
"system" : "https://twcore.mohw.gov.tw/ig/index.html",
"value" : "Bundle_EMR"
},
"type" : "document",
"timestamp" : "2023-01-04T13:01:56+08:00",
"entry" : [
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Composition/PMR-Com24",
"resource" : {
"resourceType" : "Composition",
"id" : "PMR-Com24",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRComposition"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Composition_PMR-Com24\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Composition PMR-Com24</b></p><a name=\"PMR-Com24\"> </a><a name=\"hcPMR-Com24\"> </a><a name=\"PMR-Com24-en-US\"> </a><p><b>status</b>: Final</p><p><b>type</b>: <span title=\"Codes:{http://loinc.org 18842-5}\">門診病歷</span></p><p><b>encounter</b>: <a href=\"Encounter-PMR-Enc8.html\">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)</a></p><p><b>date</b>: 2023-01-04 13:01:56+0800</p><p><b>author</b>: <a href=\"Organization-PMR-Org1.html\">Organization 國立臺灣大學醫學院附設醫院</a></p><p><b>title</b>: 門診病歷</p></div>"
},
"status" : "final",
"type" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "18842-5",
"display" : "Discharge summary"
}
],
"text" : "門診病歷"
},
"subject" : {
🔗 "reference" : "Patient/PMR-Pat2"
},
"encounter" : {
🔗 "reference" : "Encounter/PMR-Enc8"
},
"date" : "2023-01-04T13:01:56+08:00",
"author" : [
{
🔗 "reference" : "Organization/PMR-Org1"
}
],
"title" : "門診病歷",
"section" : [
{
"title" : "門診病歷中的病人基本資料_實驗室檢查紀錄",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "19146-0"
}
]
},
"entry" : [
{
🔗 "reference" : "Observation/PMR-Obs3"
}
]
},
{
"title" : "門診病歷中的病人基本資料_重大傷病",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11338-1"
}
]
},
"entry" : [
{
🔗 "reference" : "Condition/PMR-Con4"
}
]
},
{
"title" : "門診病歷中的病人基本資料_過敏史",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10155-0"
}
]
},
"entry" : [
{
🔗 "reference" : "AllergyIntolerance/PMR-All5"
}
]
},
{
"title" : "門診病歷中的病人基本資料_職業",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "21847-9"
}
]
},
"entry" : [
{
🔗 "reference" : "Observation/PMR-Obs6"
}
]
},
{
"title" : "門診病歷中的病人基本資料_就醫身分別",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "63513-6"
}
]
},
"entry" : [
{
🔗 "reference" : "Coverage/PMR-Cov7"
}
]
},
{
"title" : "門診病歷中的診斷",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29548-5"
}
]
},
"entry" : [
{
🔗 "reference" : "Condition/PMR-Con9"
}
]
},
{
"title" : "門診病歷中的診斷病情摘要_主、客觀描述與評估",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "19824-2"
}
]
},
"entry" : [
{
🔗 "reference" : "ClinicalImpression/PMR-Cli10",
"identifier" : {
"system" : "http://loinc.org",
"value" : "61150-9"
}
},
{
🔗 "reference" : "ClinicalImpression/PMR-Cli11",
"identifier" : {
"system" : "http://loinc.org",
"value" : "61149-1"
}
},
{
🔗 "reference" : "ClinicalImpression/PMR-Cli12",
"identifier" : {
"system" : "http://loinc.org",
"value" : "11494-2"
}
}
]
},
{
"title" : "門診病歷中的處置項目",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29554-3"
}
]
},
"entry" : [
{
🔗 "reference" : "Procedure/PMR-Pro13"
}
]
},
{
"title" : "門診病歷中的處方內容",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29551-9"
}
]
},
"entry" : [
{
🔗 "reference" : "MedicationRequest/PMR-MedReq14"
},
{
🔗 "reference" : "Medication/PMR-Med15"
}
]
},
{
"title" : "門診病歷中的家族圖譜",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "74027-4"
}
]
},
"entry" : [
{
🔗 "reference" : "Media/PMR-Media16"
}
]
},
{
"title" : "門診病歷中的門診圖像",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "19005-8"
}
]
},
"entry" : [
{
🔗 "reference" : "Media/PMR-Media17"
}
]
}
]
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Organization/PMR-Org1",
"resource" : {
"resourceType" : "Organization",
"id" : "PMR-Org1",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMROrganization"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Organization_PMR-Org1\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization PMR-Org1</b></p><a name=\"PMR-Org1\"> </a><a name=\"hcPMR-Org1\"> </a><a name=\"PMR-Org1-en-US\"> </a><p><b>identifier</b>: 0401180014</p><p><b>name</b>: 國立臺灣大學醫學院附設醫院</p></div>"
},
"identifier" : [
{
"value" : "0401180014"
}
],
"name" : "國立臺灣大學醫學院附設醫院"
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Patient/PMR-Pat2",
"resource" : {
"resourceType" : "Patient",
"id" : "PMR-Pat2",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRPatient"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Patient_PMR-Pat2\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Patient PMR-Pat2</b></p><a name=\"PMR-Pat2\"> </a><a name=\"hcPMR-Pat2\"> </a><a name=\"PMR-Pat2-en-US\"> </a><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">測試員 Male, DoB: 1997-01-01 ( 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=\"Record is active\">Active:</td><td colspan=\"3\">true</td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Other Id (see the one above)\">Other Id:</td><td colspan=\"3\">Medical record number/123456</td></tr></table></div>"
},
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "MR",
"display" : "Medical record number"
}
]
},
"system" : "https://www.ntuh.gov.tw/ntuh/ntuhgroup.jsp",
"value" : "123456"
},
{
"use" : "official",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "NNxxx",
"_code" : {
"extension" : [
{
"extension" : [
{
"url" : "suffix",
"valueString" : "TWN"
},
{
"url" : "valueSet",
"valueCanonical" : "http://hl7.org/fhir/ValueSet/iso3166-1-3"
}
],
"url" : "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/identifier-suffix"
}
]
}
}
]
},
"system" : "http://www.moi.gov.tw/",
"value" : "A123456789"
}
],
"active" : true,
"name" : [
{
"use" : "usual",
"text" : "測試員"
}
],
"gender" : "male",
"birthDate" : "1997-01-01"
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Observation/PMR-Obs3",
"resource" : {
"resourceType" : "Observation",
"id" : "PMR-Obs3",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRObservationLabResults"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Observation_PMR-Obs3\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Observation PMR-Obs3</b></p><a name=\"PMR-Obs3\"> </a><a name=\"hcPMR-Obs3\"> </a><a name=\"PMR-Obs3-en-US\"> </a><p><b>status</b>: Final</p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 19146-0}\">實驗室檢查紀錄</span></p><p><b>subject</b>: <a href=\"Patient-PMR-Pat2.html\">測試員 Male, DoB: 1997-01-01 ( 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>: 2023-10-01 16:52:00+0800</p><p><b>performer</b>: <a href=\"Practitioner-PMR-Pra18.html\">Practitioner 賴一施</a></p><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 10331-7}\">Rh</span></p><p><b>value</b>: <span title=\"Codes:{http://loinc.org LA6576-8}\">Rh positive</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 883-9}\">ABO group</span></p><p><b>value</b>: <span title=\"Codes:{http://loinc.org LA19709-7}\">B</span></p></blockquote></div>"
},
"status" : "final",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "19146-0",
"display" : "Referral lab test results"
}
],
"text" : "實驗室檢查紀錄"
},
"subject" : {
🔗 "reference" : "Patient/PMR-Pat2"
},
"effectiveDateTime" : "2023-10-01T16:52:00+08:00",
"performer" : [
{
🔗 "reference" : "Practitioner/PMR-Pra18"
}
],
"component" : [
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10331-7",
"display" : "Rh [Type] in Blood"
}
],
"text" : "Rh"
},
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "LA6576-8",
"display" : "Positive"
}
],
"text" : "Rh positive"
}
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "883-9",
"display" : "ABO group [Type] in Blood"
}
],
"text" : "ABO group"
},
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "LA19709-7",
"display" : "Group B"
}
],
"text" : "B"
}
}
]
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Condition/PMR-Con4",
"resource" : {
"resourceType" : "Condition",
"id" : "PMR-Con4",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRConditionMajorIllness"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Condition_PMR-Con4\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Condition PMR-Con4</b></p><a name=\"PMR-Con4\"> </a><a name=\"hcPMR-Con4\"> </a><a name=\"PMR-Con4-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://loinc.org 11338-1}\">重大傷病</span></p><p><b>code</b>: <span title=\"Codes:{https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2021-tw A15.0}\">肺結核</span></p><p><b>subject</b>: <a href=\"Patient-PMR-Pat2.html\">測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code\u00a0(use:\u00a0official,\u00a0))</a></p><p><b>note</b>: 再生不良性貧血、過敏性血管炎</p></div>"
},
"clinicalStatus" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/condition-clinical",
"code" : "active",
"display" : "Active"
}
]
},
"category" : [
{
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11338-1"
}
],
"text" : "重大傷病"
}
],
"code" : {
"coding" : [
{
"system" : "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2021-tw",
"code" : "A15.0",
"display" : "肺結核"
}
],
"text" : "肺結核"
},
"subject" : {
🔗 "reference" : "Patient/PMR-Pat2"
},
"note" : [
{
"text" : "再生不良性貧血、過敏性血管炎"
}
]
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/AllergyIntolerance/PMR-All5",
"resource" : {
"resourceType" : "AllergyIntolerance",
"id" : "PMR-All5",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRAllergyIntolerance"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"AllergyIntolerance_PMR-All5\"> </a><p class=\"res-header-id\"><b>Generated Narrative: AllergyIntolerance PMR-All5</b></p><a name=\"PMR-All5\"> </a><a name=\"hcPMR-All5\"> </a><a name=\"PMR-All5-en-US\"> </a><p><b>clinicalStatus</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical inactive}\">Inactive</span></p><p><b>verificationStatus</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/allergyintolerance-verification unconfirmed}\">Unconfirmed</span></p><p><b>code</b>: <span title=\"Codes:{http://snomed.info/sct 409137002}\">無</span></p><p><b>patient</b>: <a href=\"Patient-PMR-Pat2.html\">測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code\u00a0(use:\u00a0official,\u00a0))</a></p></div>"
},
"clinicalStatus" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical",
"code" : "inactive",
"display" : "Inactive"
}
]
},
"verificationStatus" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/allergyintolerance-verification",
"code" : "unconfirmed",
"display" : "Unconfirmed"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "409137002"
}
],
"text" : "無"
},
"patient" : {
🔗 "reference" : "Patient/PMR-Pat2"
}
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Observation/PMR-Obs6",
"resource" : {
"resourceType" : "Observation",
"id" : "PMR-Obs6",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRProfessionObservation"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Observation_PMR-Obs6\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Observation PMR-Obs6</b></p><a name=\"PMR-Obs6\"> </a><a name=\"hcPMR-Obs6\"> </a><a name=\"PMR-Obs6-en-US\"> </a><p><b>status</b>: Final</p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 21847-9}\">Usual occupation</span></p><p><b>subject</b>: <a href=\"Patient-PMR-Pat2.html\">測試員 Male, DoB: 1997-01-01 ( 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>: 2023-10-01 16:52:00+0800</p><p><b>performer</b>: <a href=\"Practitioner-PMR-Pra18.html\">Practitioner 賴一施</a></p><p><b>value</b>: 服務業/一般職員</p></div>"
},
"status" : "final",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "21847-9",
"display" : "Usual occupation"
}
],
"text" : "Usual occupation"
},
"subject" : {
🔗 "reference" : "Patient/PMR-Pat2"
},
"effectiveDateTime" : "2023-10-01T16:52:00+08:00",
"performer" : [
{
🔗 "reference" : "Practitioner/PMR-Pra18"
}
],
"valueString" : "服務業/一般職員"
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Coverage/PMR-Cov7",
"resource" : {
"resourceType" : "Coverage",
"id" : "PMR-Cov7",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/Coverage-EMR"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Coverage_PMR-Cov7\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Coverage PMR-Cov7</b></p><a name=\"PMR-Cov7\"> </a><a name=\"hcPMR-Cov7\"> </a><a name=\"PMR-Cov7-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-PMR-Pat2.html\">測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code\u00a0(use:\u00a0official,\u00a0))</a></p><p><b>payor</b>: <a href=\"Patient-PMR-Pat2.html\">測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code\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/PMR-Pat2"
},
"payor" : [
{
🔗 "reference" : "Patient/PMR-Pat2"
}
]
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Encounter/PMR-Enc8",
"resource" : {
"resourceType" : "Encounter",
"id" : "PMR-Enc8",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMREncounter"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Encounter_PMR-Enc8\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Encounter PMR-Enc8</b></p><a name=\"PMR-Enc8\"> </a><a name=\"hcPMR-Enc8\"> </a><a name=\"PMR-Enc8-en-US\"> </a><p><b>identifier</b>: <code>https://www.vghtpe.gov.tw/Index.action</code>/Encounter唯一碼, <a href=\"http://terminology.hl7.org/5.0.0/NamingSystem-v3-loinc.html\" title=\"LOINC provides a set of universal names and ID codes for identifying laboratory and clinical test results.1,2 LOINC facilitates the exchange and pooling of results, such as blood hemoglobin, serum potassium, or vital signs, for clinical care, outcomes management, and research. LOINC's universal identifiers (names and codes) can be used in the context of order and observation exchanges between information systems that use syntax standards such as HL73, CEN TC251, ISO TC215, ASTM4, and DICOM. Specifically, the identifier can be used as the coded value for an observation in any other standard that uses the observation/observation value paradigm, whether messages, documents, application programming interface (API), etc. For example, LOINC codes are used widely in the OBX segment Observation Identifier field (OBX-3) of an ORU HL7 (HL7 version 2.x or ASTM 1238-9410) message that may be sent between a Clinical Laboratory Information Management Systems (LIMS) and Electronic Health Record Systems (EHR).5, 6 In this way, LOINC codes provide universal identifiers that allow the exchange of clinical data between heterogeneous computing environments.\">LOINC</a>/8653-8</p><p><b>status</b>: Finished</p><p><b>class</b>: v3-ActEncounterCode AMB: ambulatory</p><p><b>serviceType</b>: <span title=\"Codes:{http://snomed.info/sct 394609007}\">Medical Services</span></p><p><b>period</b>: 2022-07-08 12:12:00+0000 --> (ongoing)</p></div>"
},
"identifier" : [
{
"system" : "https://www.vghtpe.gov.tw/Index.action",
"value" : "Encounter唯一碼"
},
{
"system" : "http://loinc.org",
"value" : "8653-8"
}
],
"status" : "finished",
"class" : {
"system" : "http://terminology.hl7.org/CodeSystem/v3-ActEncounterCode",
"code" : "AMB",
"display" : "ambulatory"
},
"serviceType" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "394609007"
}
],
"text" : "Medical Services"
},
"period" : {
"start" : "2022-07-08T12:12:00.000Z"
}
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Condition/PMR-Con9",
"resource" : {
"resourceType" : "Condition",
"id" : "PMR-Con9",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRConditionDiagnosis"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Condition_PMR-Con9\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Condition PMR-Con9</b></p><a name=\"PMR-Con9\"> </a><a name=\"hcPMR-Con9\"> </a><a name=\"PMR-Con9-en-US\"> </a><p><b>clinicalStatus</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/condition-clinical active}\">診斷</span></p><p><b>category</b>: <span title=\"Codes:{http://loinc.org 29548-5}\">診斷</span></p><p><b>code</b>: <span title=\"Codes:{https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-9-cm-2001-tw 011.00}\">結核病(Tuberculosis)</span></p><p><b>subject</b>: <a href=\"Patient-PMR-Pat2.html\">測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code\u00a0(use:\u00a0official,\u00a0))</a></p><p><b>note</b>: 未確認流感病毒所致流行性感冒併明示類型肺炎</p></div>"
},
"clinicalStatus" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/condition-clinical",
"code" : "active",
"display" : "Active"
}
],
"text" : "診斷"
},
"category" : [
{
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29548-5"
}
],
"text" : "診斷"
}
],
"code" : {
"coding" : [
{
"system" : "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-9-cm-2001-tw",
"code" : "011.00",
"display" : "浸潤性肺結核"
}
],
"text" : "結核病(Tuberculosis)"
},
"subject" : {
🔗 "reference" : "Patient/PMR-Pat2"
},
"note" : [
{
"text" : "未確認流感病毒所致流行性感冒併明示類型肺炎"
}
]
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/ClinicalImpression/PMR-Cli10",
"resource" : {
"resourceType" : "ClinicalImpression",
"id" : "PMR-Cli10",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRClinicalImpressionSubjective"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"ClinicalImpression_PMR-Cli10\"> </a><p class=\"res-header-id\"><b>Generated Narrative: ClinicalImpression PMR-Cli10</b></p><a name=\"PMR-Cli10\"> </a><a name=\"hcPMR-Cli10\"> </a><a name=\"PMR-Cli10-en-US\"> </a><p><b>status</b>: Completed</p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 61150-9}\">Subjective</span></p><p><b>subject</b>: <a href=\"Patient-PMR-Pat2.html\">測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code\u00a0(use:\u00a0official,\u00a0))</a></p><p><b>note</b>: 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</p></div>"
},
"status" : "completed",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "61150-9",
"display" : "Subjective"
}
],
"text" : "Subjective"
},
"subject" : {
🔗 "reference" : "Patient/PMR-Pat2"
},
"note" : [
{
"text" : "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"
}
]
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/ClinicalImpression/PMR-Cli11",
"resource" : {
"resourceType" : "ClinicalImpression",
"id" : "PMR-Cli11",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRClinicalImpressionObjective"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"ClinicalImpression_PMR-Cli11\"> </a><p class=\"res-header-id\"><b>Generated Narrative: ClinicalImpression PMR-Cli11</b></p><a name=\"PMR-Cli11\"> </a><a name=\"hcPMR-Cli11\"> </a><a name=\"PMR-Cli11-en-US\"> </a><p><b>status</b>: Completed</p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 61149-1}\">Objective</span></p><p><b>subject</b>: <a href=\"Patient-PMR-Pat2.html\">測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code\u00a0(use:\u00a0official,\u00a0))</a></p><p><b>note</b>: 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</p></div>"
},
"status" : "completed",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "61149-1",
"display" : "Objective"
}
],
"text" : "Objective"
},
"subject" : {
🔗 "reference" : "Patient/PMR-Pat2"
},
"note" : [
{
"text" : "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"
}
]
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/ClinicalImpression/PMR-Cli12",
"resource" : {
"resourceType" : "ClinicalImpression",
"id" : "PMR-Cli12",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRClinicalImpressionAssessment"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"ClinicalImpression_PMR-Cli12\"> </a><p class=\"res-header-id\"><b>Generated Narrative: ClinicalImpression PMR-Cli12</b></p><a name=\"PMR-Cli12\"> </a><a name=\"hcPMR-Cli12\"> </a><a name=\"PMR-Cli12-en-US\"> </a><p><b>status</b>: Completed</p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 11494-2}\">Deprecated Physician Initial assessment note at First encounter</span></p><p><b>subject</b>: <a href=\"Patient-PMR-Pat2.html\">測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code\u00a0(use:\u00a0official,\u00a0))</a></p><p><b>note</b>: HCVD</p></div>"
},
"status" : "completed",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11494-2",
"display" : "Deprecated Physician Initial assessment note at First encounter"
}
],
"text" : "Deprecated Physician Initial assessment note at First encounter"
},
"subject" : {
🔗 "reference" : "Patient/PMR-Pat2"
},
"note" : [
{
"text" : "HCVD"
}
]
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Procedure/PMR-Pro13",
"resource" : {
"resourceType" : "Procedure",
"id" : "PMR-Pro13",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRProcedure"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Procedure_PMR-Pro13\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Procedure PMR-Pro13</b></p><a name=\"PMR-Pro13\"> </a><a name=\"hcPMR-Pro13\"> </a><a name=\"PMR-Pro13-en-US\"> </a><p><b>identifier</b>: <code>https://www.vghtpe.gov.tw/Index.action</code>/1</p><p><b>status</b>: Completed</p><p><b>code</b>: <span title=\"Codes:{https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-pcs-2021-tw BU46ZZZ}\">Procedure</span></p><p><b>subject</b>: <a href=\"Patient-PMR-Pat2.html\">測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code\u00a0(use:\u00a0official,\u00a0))</a></p><p><b>bodySite</b>: <span title=\"Codes:{http://snomed.info/sct 9258009}\">妊娠子宮</span></p><p><b>followUp</b>: <span title=\"Codes:\">一次性處置</span>, <span title=\"Codes:\">1</span>, <span title=\"Codes:\">次</span></p><p><b>note</b>: 持續追蹤</p></div>"
},
"identifier" : [
{
"system" : "https://www.vghtpe.gov.tw/Index.action",
"value" : "1"
}
],
"status" : "completed",
"code" : {
"coding" : [
{
"system" : "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-pcs-2021-tw",
"code" : "BU46ZZZ"
}
],
"text" : "Procedure"
},
"subject" : {
🔗 "reference" : "Patient/PMR-Pat2"
},
"bodySite" : [
{
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "9258009"
}
],
"text" : "妊娠子宮"
}
],
"followUp" : [
{
"text" : "一次性處置"
},
{
"text" : "1"
},
{
"text" : "次"
}
],
"note" : [
{
"text" : " 持續追蹤"
}
]
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/MedicationRequest/PMR-MedReq14",
"resource" : {
"resourceType" : "MedicationRequest",
"id" : "PMR-MedReq14",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRMedicationRequest"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"MedicationRequest_PMR-MedReq14\"> </a><p class=\"res-header-id\"><b>Generated Narrative: MedicationRequest PMR-MedReq14</b></p><a name=\"PMR-MedReq14\"> </a><a name=\"hcPMR-MedReq14\"> </a><a name=\"PMR-MedReq14-en-US\"> </a><p><b>identifier</b>: <code>https://www.vghtpe.gov.tw/Index.action</code>/項次id</p><p><b>status</b>: Completed</p><p><b>intent</b>: Order</p><p><b>category</b>: <span title=\"Codes:{http://loinc.org 29551-9}\">Medication prescribed</span></p><p><b>medication</b>: <a href=\"Medication-PMR-Med15.html\">Medication 阿立批挫</a></p><p><b>subject</b>: <a href=\"Patient-PMR-Pat2.html\">測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code\u00a0(use:\u00a0official,\u00a0))</a></p><blockquote><p><b>dosageInstruction</b></p></blockquote><blockquote><p><b>dispenseRequest</b></p><p><b>validityPeriod</b>: 2020-07-01 --> 2020-07-31</p><p><b>numberOfRepeatsAllowed</b>: 1</p><p><b>quantity</b>: 31 TAB<span style=\"background: LightGoldenRodYellow\"> (Details: Orderable Drug Form codeTAB = 'Tablet')</span></p><h3>ExpectedSupplyDurations</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Unit</b></td><td><b>System</b></td><td><b>Code</b></td></tr><tr><td style=\"display: none\">*</td><td>31</td><td>days</td><td><a href=\"http://terminology.hl7.org/6.0.2/CodeSystem-v3-ucum.html\">http://unitsofmeasure.org</a></td><td>d</td></tr></table></blockquote></div>"
},
"identifier" : [
{
"system" : "https://www.vghtpe.gov.tw/Index.action",
"value" : "項次id"
}
],
"status" : "completed",
"intent" : "order",
"category" : [
{
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29551-9",
"display" : "Medication prescribed"
}
],
"text" : "Medication prescribed"
}
],
"medicationReference" : {
🔗 "reference" : "Medication/PMR-Med15"
},
"subject" : {
🔗 "reference" : "Patient/PMR-Pat2"
},
"dosageInstruction" : [
{
"sequence" : 1,
"text" : "高血壓藥",
"timing" : {
"code" : {
"coding" : [
{
"system" : "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medication-frequency-tw",
"code" : "QD",
"display" : "每日一次"
}
],
"text" : "每日一次"
}
},
"route" : {
"coding" : [
{
"system" : "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medication-path-tw",
"code" : "PO",
"display" : "口眼"
}
],
"text" : "口服"
},
"doseAndRate" : [
{
"doseQuantity" : {
"value" : 1,
"unit" : "days"
}
}
]
}
],
"dispenseRequest" : {
"validityPeriod" : {
"start" : "2020-07-01",
"end" : "2020-07-31"
},
"numberOfRepeatsAllowed" : 1,
"quantity" : {
"value" : 31,
"unit" : "TAB",
"system" : "http://terminology.hl7.org/CodeSystem/v3-orderableDrugForm",
"code" : "TAB"
},
"expectedSupplyDuration" : {
"value" : 31,
"unit" : "days",
"system" : "http://unitsofmeasure.org",
"code" : "d"
}
}
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Medication/PMR-Med15",
"resource" : {
"resourceType" : "Medication",
"id" : "PMR-Med15",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRMedication"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Medication_PMR-Med15\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Medication PMR-Med15</b></p><a name=\"PMR-Med15\"> </a><a name=\"hcPMR-Med15\"> </a><a name=\"PMR-Med15-en-US\"> </a><p><b>code</b>: <span title=\"Codes:{https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medication-fda-tw 衛署藥輸字第025485號}\">阿立批挫</span></p><p><b>form</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-orderableDrugForm POWD}\">粉</span></p></div>"
},
"code" : {
"coding" : [
{
"system" : "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medication-fda-tw",
"code" : "衛署藥輸字第025485號",
"display" : "阿立批挫"
}
],
"text" : "阿立批挫"
},
"form" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-orderableDrugForm",
"code" : "POWD"
}
],
"text" : "粉"
}
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Media/PMR-Media16",
"resource" : {
"resourceType" : "Media",
"id" : "PMR-Media16",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRFamilyTreeMedia"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Media_PMR-Media16\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Media PMR-Media16</b></p><a name=\"PMR-Media16\"> </a><a name=\"hcPMR-Media16\"> </a><a name=\"PMR-Media16-en-US\"> </a><p><b>status</b>: Completed</p><p><b>type</b>: <span title=\"Codes:{http://loinc.org 74027-4}\">家族圖譜</span></p><p><b>subject</b>: <a href=\"Patient-PMR-Pat2.html\">測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code\u00a0(use:\u00a0official,\u00a0))</a></p><h3>Contents</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>ContentType</b></td><td><b>Url</b></td><td><b>Title</b></td></tr><tr><td style=\"display: none\">*</td><td>image/jpeg</td><td>Url</td><td>家族圖譜</td></tr></table></div>"
},
"status" : "completed",
"type" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "74027-4"
}
],
"text" : "家族圖譜"
},
"subject" : {
🔗 "reference" : "Patient/PMR-Pat2"
},
"content" : {
"contentType" : "image/jpeg",
"url" : "Url",
"title" : "家族圖譜"
}
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Media/PMR-Media17",
"resource" : {
"resourceType" : "Media",
"id" : "PMR-Media17",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMROutpatientImageMedia"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Media_PMR-Media17\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Media PMR-Media17</b></p><a name=\"PMR-Media17\"> </a><a name=\"hcPMR-Media17\"> </a><a name=\"PMR-Media17-en-US\"> </a><p><b>status</b>: Completed</p><p><b>type</b>: <span title=\"Codes:{http://loinc.org 19005-8}\">門診圖像</span></p><p><b>subject</b>: <a href=\"Patient-PMR-Pat2.html\">測試員 Male, DoB: 1997-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code\u00a0(use:\u00a0official,\u00a0))</a></p><h3>Contents</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>ContentType</b></td><td><b>Url</b></td><td><b>Title</b></td></tr><tr><td style=\"display: none\">*</td><td>application/dicom</td><td>Url</td><td>門診圖像</td></tr></table></div>"
},
"status" : "completed",
"type" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "19005-8"
}
],
"text" : "門診圖像"
},
"subject" : {
🔗 "reference" : "Patient/PMR-Pat2"
},
"content" : {
"contentType" : "application/dicom",
"url" : "Url",
"title" : "門診圖像"
}
}
},
{
"fullUrl" : "https://twcore.mohw.gov.tw/ig/emr/Practitioner/PMR-Pra18",
"resource" : {
"resourceType" : "Practitioner",
"id" : "PMR-Pra18",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRPractitioner"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Practitioner_PMR-Pra18\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Practitioner PMR-Pra18</b></p><a name=\"PMR-Pra18\"> </a><a name=\"hcPMR-Pra18\"> </a><a name=\"PMR-Pra18-en-US\"> </a><p><b>identifier</b>: <code>https://www.vghtpe.gov.tw/Index.action</code>/123</p><p><b>name</b>: 賴一施</p></div>"
},
"identifier" : [
{
"system" : "https://www.vghtpe.gov.tw/Index.action",
"value" : "123"
}
],
"name" : [
{
"text" : "賴一施"
}
]
}
}
]
}