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
<Bundle xmlns="http://hl7.org/fhir">
<id value="example-PMR"/>
<meta>
<profile
value="https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRBundle"/>
</meta>
<identifier>
<system value="https://twcore.mohw.gov.tw/ig/index.html"/>
<value value="Bundle_EMR"/>
</identifier>
<type value="document"/>
<timestamp value="2023-01-04T13:01:56+08:00"/>
<entry>
<fullUrl value="https://twcore.mohw.gov.tw/ig/emr/Composition/PMR-Com24"/>
<resource>
<Composition>
<id value="PMR-Com24"/>
<meta>
<profile
value="https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRComposition"/>
</meta>
<text>
<status value="generated"/>
<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>
</text>
<status value="final"/>
<type>
<coding>
<system value="http://loinc.org"/>
<code value="18842-5"/>
<display value="Discharge summary"/>
</coding>
<text value="門診病歷"/>
</type>
<subject>🔗
<reference value="Patient/PMR-Pat2"/>
</subject>
<encounter>🔗
<reference value="Encounter/PMR-Enc8"/>
</encounter>
<date value="2023-01-04T13:01:56+08:00"/>
<author>🔗
<reference value="Organization/PMR-Org1"/>
</author>
<title value="門診病歷"/>
<section>
<title value="門診病歷中的病人基本資料_實驗室檢查紀錄"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="19146-0"/>
</coding>
</code>
<entry>🔗
<reference value="Observation/PMR-Obs3"/>
</entry>
</section>
<section>
<title value="門診病歷中的病人基本資料_重大傷病"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11338-1"/>
</coding>
</code>
<entry>🔗
<reference value="Condition/PMR-Con4"/>
</entry>
</section>
<section>
<title value="門診病歷中的病人基本資料_過敏史"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10155-0"/>
</coding>
</code>
<entry>🔗
<reference value="AllergyIntolerance/PMR-All5"/>
</entry>
</section>
<section>
<title value="門診病歷中的病人基本資料_職業"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="21847-9"/>
</coding>
</code>
<entry>🔗
<reference value="Observation/PMR-Obs6"/>
</entry>
</section>
<section>
<title value="門診病歷中的病人基本資料_就醫身分別"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="63513-6"/>
</coding>
</code>
<entry>🔗
<reference value="Coverage/PMR-Cov7"/>
</entry>
</section>
<section>
<title value="門診病歷中的診斷"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="29548-5"/>
</coding>
</code>
<entry>🔗
<reference value="Condition/PMR-Con9"/>
</entry>
</section>
<section>
<title value="門診病歷中的診斷病情摘要_主、客觀描述與評估"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="19824-2"/>
</coding>
</code>
<entry>🔗
<reference value="ClinicalImpression/PMR-Cli10"/>
<identifier>
<system value="http://loinc.org"/>
<value value="61150-9"/>
</identifier>
</entry>
<entry>🔗
<reference value="ClinicalImpression/PMR-Cli11"/>
<identifier>
<system value="http://loinc.org"/>
<value value="61149-1"/>
</identifier>
</entry>
<entry>🔗
<reference value="ClinicalImpression/PMR-Cli12"/>
<identifier>
<system value="http://loinc.org"/>
<value value="11494-2"/>
</identifier>
</entry>
</section>
<section>
<title value="門診病歷中的處置項目"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="29554-3"/>
</coding>
</code>
<entry>🔗
<reference value="Procedure/PMR-Pro13"/>
</entry>
</section>
<section>
<title value="門診病歷中的處方內容"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="29551-9"/>
</coding>
</code>
<entry>🔗
<reference value="MedicationRequest/PMR-MedReq14"/>
</entry>
<entry>🔗
<reference value="Medication/PMR-Med15"/>
</entry>
</section>
<section>
<title value="門診病歷中的家族圖譜"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="74027-4"/>
</coding>
</code>
<entry>🔗
<reference value="Media/PMR-Media16"/>
</entry>
</section>
<section>
<title value="門診病歷中的門診圖像"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="19005-8"/>
</coding>
</code>
<entry>🔗
<reference value="Media/PMR-Media17"/>
</entry>
</section>
</Composition>
</resource>
</entry>
<entry>
<fullUrl value="https://twcore.mohw.gov.tw/ig/emr/Organization/PMR-Org1"/>
<resource>
<Organization>
<id value="PMR-Org1"/>
<meta>
<profile
value="https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMROrganization"/>
</meta>
<text>
<status value="generated"/>
<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>
</text>
<identifier>
<value value="0401180014"/>
</identifier>
<name value="國立臺灣大學醫學院附設醫院"/>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="https://twcore.mohw.gov.tw/ig/emr/Patient/PMR-Pat2"/>
<resource>
<Patient>
<id value="PMR-Pat2"/>
<meta>
<profile
value="https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRPatient"/>
</meta>
<text>
<status value="generated"/>
<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 (use: official, ))</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>
</text>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="MR"/>
<display value="Medical record number"/>
</coding>
</type>
<system value="https://www.ntuh.gov.tw/ntuh/ntuhgroup.jsp"/>
<value value="123456"/>
</identifier>
<identifier>
<use value="official"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="NNxxx">
<extension
url="https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/identifier-suffix">
<extension url="suffix">
<valueString value="TWN"/>
</extension>
<extension url="valueSet">
<valueCanonical
value="http://hl7.org/fhir/ValueSet/iso3166-1-3"/>
</extension>
</extension>
</code>
</coding>
</type>
<system value="http://www.moi.gov.tw/"/>
<value value="A123456789"/>
</identifier>
<active value="true"/>
<name>
<use value="usual"/>
<text value="測試員"/>
</name>
<gender value="male"/>
<birthDate value="1997-01-01"/>
</Patient>
</resource>
</entry>
<entry>
<fullUrl value="https://twcore.mohw.gov.tw/ig/emr/Observation/PMR-Obs3"/>
<resource>
<Observation>
<id value="PMR-Obs3"/>
<meta>
<profile
value="https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRObservationLabResults"/>
</meta>
<text>
<status value="generated"/>
<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 (use: official, ))</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>
</text>
<status value="final"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="19146-0"/>
<display value="Referral lab test results"/>
</coding>
<text value="實驗室檢查紀錄"/>
</code>
<subject>🔗
<reference value="Patient/PMR-Pat2"/>
</subject>
<effectiveDateTime value="2023-10-01T16:52:00+08:00"/>
<performer>🔗
<reference value="Practitioner/PMR-Pra18"/>
</performer>
<component>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10331-7"/>
<display value="Rh [Type] in Blood"/>
</coding>
<text value="Rh"/>
</code>
<valueCodeableConcept>
<coding>
<system value="http://loinc.org"/>
<code value="LA6576-8"/>
<display value="Positive"/>
</coding>
<text value="Rh positive"/>
</valueCodeableConcept>
</component>
<component>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="883-9"/>
<display value="ABO group [Type] in Blood"/>
</coding>
<text value="ABO group"/>
</code>
<valueCodeableConcept>
<coding>
<system value="http://loinc.org"/>
<code value="LA19709-7"/>
<display value="Group B"/>
</coding>
<text value="B"/>
</valueCodeableConcept>
</component>
</Observation>
</resource>
</entry>
<entry>
<fullUrl value="https://twcore.mohw.gov.tw/ig/emr/Condition/PMR-Con4"/>
<resource>
<Condition>
<id value="PMR-Con4"/>
<meta>
<profile
value="https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRConditionMajorIllness"/>
</meta>
<text>
<status value="generated"/>
<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 (use: official, ))</a></p><p><b>note</b>: 再生不良性貧血、過敏性血管炎</p></div>
</text>
<clinicalStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
<code value="active"/>
<display value="Active"/>
</coding>
</clinicalStatus>
<category>
<coding>
<system value="http://loinc.org"/>
<code value="11338-1"/>
</coding>
<text value="重大傷病"/>
</category>
<code>
<coding>
<system
value="https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2021-tw"/>
<code value="A15.0"/>
<display value="肺結核"/>
</coding>
<text value="肺結核"/>
</code>
<subject>🔗
<reference value="Patient/PMR-Pat2"/>
</subject>
<note>
<text value="再生不良性貧血、過敏性血管炎"/>
</note>
</Condition>
</resource>
</entry>
<entry>
<fullUrl
value="https://twcore.mohw.gov.tw/ig/emr/AllergyIntolerance/PMR-All5"/>
<resource>
<AllergyIntolerance>
<id value="PMR-All5"/>
<meta>
<profile
value="https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRAllergyIntolerance"/>
</meta>
<text>
<status value="generated"/>
<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 (use: official, ))</a></p></div>
</text>
<clinicalStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical"/>
<code value="inactive"/>
<display value="Inactive"/>
</coding>
</clinicalStatus>
<verificationStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/allergyintolerance-verification"/>
<code value="unconfirmed"/>
<display value="Unconfirmed"/>
</coding>
</verificationStatus>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="409137002"/>
</coding>
<text value="無"/>
</code>
<patient>🔗
<reference value="Patient/PMR-Pat2"/>
</patient>
</AllergyIntolerance>
</resource>
</entry>
<entry>
<fullUrl value="https://twcore.mohw.gov.tw/ig/emr/Observation/PMR-Obs6"/>
<resource>
<Observation>
<id value="PMR-Obs6"/>
<meta>
<profile
value="https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRProfessionObservation"/>
</meta>
<text>
<status value="generated"/>
<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 (use: official, ))</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>
</text>
<status value="final"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="21847-9"/>
<display value="Usual occupation"/>
</coding>
<text value="Usual occupation"/>
</code>
<subject>🔗
<reference value="Patient/PMR-Pat2"/>
</subject>
<effectiveDateTime value="2023-10-01T16:52:00+08:00"/>
<performer>🔗
<reference value="Practitioner/PMR-Pra18"/>
</performer>
<valueString value="服務業/一般職員"/>
</Observation>
</resource>
</entry>
<entry>
<fullUrl value="https://twcore.mohw.gov.tw/ig/emr/Coverage/PMR-Cov7"/>
<resource>
<Coverage>
<id value="PMR-Cov7"/>
<meta>
<profile
value="https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/Coverage-EMR"/>
</meta>
<text>
<status value="generated"/>
<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 (use: official, ))</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 (use: official, ))</a></p></div>
</text>
<status value="active"/>
<type>
<coding>
<system
value="https://twcore.mohw.gov.tw/ig/emr/CodeSystem/paymentcategory"/>
<code value="1"/>
<display value="職業傷害"/>
</coding>
</type>
<beneficiary>🔗
<reference value="Patient/PMR-Pat2"/>
</beneficiary>
<payor>🔗
<reference value="Patient/PMR-Pat2"/>
</payor>
</Coverage>
</resource>
</entry>
<entry>
<fullUrl value="https://twcore.mohw.gov.tw/ig/emr/Encounter/PMR-Enc8"/>
<resource>
<Encounter>
<id value="PMR-Enc8"/>
<meta>
<profile
value="https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMREncounter"/>
</meta>
<text>
<status value="generated"/>
<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>
</text>
<identifier>
<system value="https://www.vghtpe.gov.tw/Index.action"/>
<value value="Encounter唯一碼"/>
</identifier>
<identifier>
<system value="http://loinc.org"/>
<value value="8653-8"/>
</identifier>
<status value="finished"/>
<class>
<system
value="http://terminology.hl7.org/CodeSystem/v3-ActEncounterCode"/>
<code value="AMB"/>
<display value="ambulatory"/>
</class>
<serviceType>
<coding>
<system value="http://snomed.info/sct"/>
<code value="394609007"/>
</coding>
<text value="Medical Services"/>
</serviceType>
<period>
<start value="2022-07-08T12:12:00.000Z"/>
</period>
</Encounter>
</resource>
</entry>
<entry>
<fullUrl value="https://twcore.mohw.gov.tw/ig/emr/Condition/PMR-Con9"/>
<resource>
<Condition>
<id value="PMR-Con9"/>
<meta>
<profile
value="https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRConditionDiagnosis"/>
</meta>
<text>
<status value="generated"/>
<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 (use: official, ))</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>
</text>
<clinicalStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
<code value="active"/>
<display value="Active"/>
</coding>
<text value="診斷"/>
</clinicalStatus>
<category>
<coding>
<system value="http://loinc.org"/>
<code value="29548-5"/>
</coding>
<text value="診斷"/>
</category>
<code>
<coding>
<system
value="https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-9-cm-2001-tw"/>
<code value="011.00"/>
<display value="浸潤性肺結核"/>
</coding>
<text value="結核病(Tuberculosis)"/>
</code>
<subject>🔗
<reference value="Patient/PMR-Pat2"/>
</subject>
<note>
<text value="未確認流感病毒所致流行性感冒併明示類型肺炎"/>
</note>
</Condition>
</resource>
</entry>
<entry>
<fullUrl
value="https://twcore.mohw.gov.tw/ig/emr/ClinicalImpression/PMR-Cli10"/>
<resource>
<ClinicalImpression>
<id value="PMR-Cli10"/>
<meta>
<profile
value="https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRClinicalImpressionSubjective"/>
</meta>
<text>
<status value="generated"/>
<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 (use: official, ))</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>
</text>
<status value="completed"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="61150-9"/>
<display value="Subjective"/>
</coding>
<text value="Subjective"/>
</code>
<subject>🔗
<reference value="Patient/PMR-Pat2"/>
</subject>
<note>
<text
value="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"/>
</note>
</ClinicalImpression>
</resource>
</entry>
<entry>
<fullUrl
value="https://twcore.mohw.gov.tw/ig/emr/ClinicalImpression/PMR-Cli11"/>
<resource>
<ClinicalImpression>
<id value="PMR-Cli11"/>
<meta>
<profile
value="https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRClinicalImpressionObjective"/>
</meta>
<text>
<status value="generated"/>
<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 (use: official, ))</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>
</text>
<status value="completed"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="61149-1"/>
<display value="Objective"/>
</coding>
<text value="Objective"/>
</code>
<subject>🔗
<reference value="Patient/PMR-Pat2"/>
</subject>
<note>
<text
value="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"/>
</note>
</ClinicalImpression>
</resource>
</entry>
<entry>
<fullUrl
value="https://twcore.mohw.gov.tw/ig/emr/ClinicalImpression/PMR-Cli12"/>
<resource>
<ClinicalImpression>
<id value="PMR-Cli12"/>
<meta>
<profile
value="https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRClinicalImpressionAssessment"/>
</meta>
<text>
<status value="generated"/>
<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 (use: official, ))</a></p><p><b>note</b>: HCVD</p></div>
</text>
<status value="completed"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11494-2"/>
<display
value="Deprecated Physician Initial assessment note at First encounter"/>
</coding>
<text
value="Deprecated Physician Initial assessment note at First encounter"/>
</code>
<subject>🔗
<reference value="Patient/PMR-Pat2"/>
</subject>
<note>
<text value="HCVD"/>
</note>
</ClinicalImpression>
</resource>
</entry>
<entry>
<fullUrl value="https://twcore.mohw.gov.tw/ig/emr/Procedure/PMR-Pro13"/>
<resource>
<Procedure>
<id value="PMR-Pro13"/>
<meta>
<profile
value="https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRProcedure"/>
</meta>
<text>
<status value="generated"/>
<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 (use: official, ))</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>
</text>
<identifier>
<system value="https://www.vghtpe.gov.tw/Index.action"/>
<value value="1"/>
</identifier>
<status value="completed"/>
<code>
<coding>
<system
value="https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-pcs-2021-tw"/>
<code value="BU46ZZZ"/>
</coding>
<text value="Procedure"/>
</code>
<subject>🔗
<reference value="Patient/PMR-Pat2"/>
</subject>
<bodySite>
<coding>
<system value="http://snomed.info/sct"/>
<code value="9258009"/>
</coding>
<text value="妊娠子宮"/>
</bodySite>
<followUp>
<text value="一次性處置"/>
</followUp>
<followUp>
<text value="1"/>
</followUp>
<followUp>
<text value="次"/>
</followUp>
<note>
<text value=" 持續追蹤"/>
</note>
</Procedure>
</resource>
</entry>
<entry>
<fullUrl
value="https://twcore.mohw.gov.tw/ig/emr/MedicationRequest/PMR-MedReq14"/>
<resource>
<MedicationRequest>
<id value="PMR-MedReq14"/>
<meta>
<profile
value="https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRMedicationRequest"/>
</meta>
<text>
<status value="generated"/>
<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 (use: official, ))</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>
</text>
<identifier>
<system value="https://www.vghtpe.gov.tw/Index.action"/>
<value value="項次id"/>
</identifier>
<status value="completed"/>
<intent value="order"/>
<category>
<coding>
<system value="http://loinc.org"/>
<code value="29551-9"/>
<display value="Medication prescribed"/>
</coding>
<text value="Medication prescribed"/>
</category>
<medicationReference>🔗
<reference value="Medication/PMR-Med15"/>
</medicationReference>
<subject>🔗
<reference value="Patient/PMR-Pat2"/>
</subject>
<dosageInstruction>
<sequence value="1"/>
<text value="高血壓藥"/>
<timing>
<code>
<coding>
<system
value="https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medication-frequency-tw"/>
<code value="QD"/>
<display value="每日一次"/>
</coding>
<text value="每日一次"/>
</code>
</timing>
<route>
<coding>
<system
value="https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medication-path-tw"/>
<code value="PO"/>
<display value="口眼"/>
</coding>
<text value="口服"/>
</route>
<doseAndRate>
<doseQuantity>
<value value="1"/>
<unit value="days"/>
</doseQuantity>
</doseAndRate>
</dosageInstruction>
<dispenseRequest>
<validityPeriod>
<start value="2020-07-01"/>
<end value="2020-07-31"/>
</validityPeriod>
<numberOfRepeatsAllowed value="1"/>
<quantity>
<value value="31"/>
<unit value="TAB"/>
<system
value="http://terminology.hl7.org/CodeSystem/v3-orderableDrugForm"/>
<code value="TAB"/>
</quantity>
<expectedSupplyDuration>
<value value="31"/>
<unit value="days"/>
<system value="http://unitsofmeasure.org"/>
<code value="d"/>
</expectedSupplyDuration>
</dispenseRequest>
</MedicationRequest>
</resource>
</entry>
<entry>
<fullUrl value="https://twcore.mohw.gov.tw/ig/emr/Medication/PMR-Med15"/>
<resource>
<Medication>
<id value="PMR-Med15"/>
<meta>
<profile
value="https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRMedication"/>
</meta>
<text>
<status value="generated"/>
<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>
</text>
<code>
<coding>
<system
value="https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medication-fda-tw"/>
<code value="衛署藥輸字第025485號"/>
<display value="阿立批挫"/>
</coding>
<text value="阿立批挫"/>
</code>
<form>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-orderableDrugForm"/>
<code value="POWD"/>
</coding>
<text value="粉"/>
</form>
</Medication>
</resource>
</entry>
<entry>
<fullUrl value="https://twcore.mohw.gov.tw/ig/emr/Media/PMR-Media16"/>
<resource>
<Media>
<id value="PMR-Media16"/>
<meta>
<profile
value="https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRFamilyTreeMedia"/>
</meta>
<text>
<status value="generated"/>
<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 (use: official, ))</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>
</text>
<status value="completed"/>
<type>
<coding>
<system value="http://loinc.org"/>
<code value="74027-4"/>
</coding>
<text value="家族圖譜"/>
</type>
<subject>🔗
<reference value="Patient/PMR-Pat2"/>
</subject>
<content>
<contentType value="image/jpeg"/>
<url value="Url"/>
<title value="家族圖譜"/>
</content>
</Media>
</resource>
</entry>
<entry>
<fullUrl value="https://twcore.mohw.gov.tw/ig/emr/Media/PMR-Media17"/>
<resource>
<Media>
<id value="PMR-Media17"/>
<meta>
<profile
value="https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMROutpatientImageMedia"/>
</meta>
<text>
<status value="generated"/>
<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 (use: official, ))</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>
</text>
<status value="completed"/>
<type>
<coding>
<system value="http://loinc.org"/>
<code value="19005-8"/>
</coding>
<text value="門診圖像"/>
</type>
<subject>🔗
<reference value="Patient/PMR-Pat2"/>
</subject>
<content>
<contentType value="application/dicom"/>
<url value="Url"/>
<title value="門診圖像"/>
</content>
</Media>
</resource>
</entry>
<entry>
<fullUrl
value="https://twcore.mohw.gov.tw/ig/emr/Practitioner/PMR-Pra18"/>
<resource>
<Practitioner>
<id value="PMR-Pra18"/>
<meta>
<profile
value="https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRPractitioner"/>
</meta>
<text>
<status value="generated"/>
<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>
</text>
<identifier>
<system value="https://www.vghtpe.gov.tw/Index.action"/>
<value value="123"/>
</identifier>
<name>
<text value="賴一施"/>
</name>
</Practitioner>
</resource>
</entry>
</Bundle>