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" : "Composition",
"id" : "DMS-Com24",
"meta" : {
"profile" : [
🔗 "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/CompositionDMS"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Composition DMS-Com24</b></p><a name=\"DMS-Com24\"> </a><a name=\"hcDMS-Com24\"> </a><a name=\"DMS-Com24-en-US\"> </a><p><b>status</b>: Final</p><p><b>type</b>: <span title=\"Codes:{http://loinc.org 11490-0}\">出院病摘</span></p><p><b>encounter</b>: <a href=\"Encounter-DMS-Enc3.html\">Encounter: status = finished; class = inpatient encounter (ActCode#IMP); serviceType = General surgery (qualifier value); period = 2022-07-08 12:12:00+0000 --> 2022-07-09 12:12:00+0000</a></p><p><b>date</b>: 2023-01-04 13:01:56+0800</p><p><b>author</b>: </p><ul><li><a href=\"Organization-DMS-Org1.html\">Organization 國立臺灣大學醫學院附設醫院</a></li><li><a href=\"Organization-DMS-Org6.html\">Organization 轉入醫事機構名稱</a></li><li><a href=\"Organization-DMS-Org22.html\">Organization 轉出醫事機構名稱</a></li><li><a href=\"Practitioner-DMS-Pra23.html\">Practitioner 賴一施</a></li></ul><p><b>title</b>: 出院病摘</p><p><b>custodian</b>: <a href=\"Organization-DMS-Org1.html\">Organization 國立臺灣大學醫學院附設醫院</a></p></div>"
},
"status" : "final",
"type" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11490-0",
"display" : "Physician Discharge summary"
}
],
"text" : "出院病摘"
},
"subject" : {
🔗 "reference" : "Patient/DMS-Pat2"
},
"encounter" : {
🔗 "reference" : "Encounter/DMS-Enc3"
},
"date" : "2023-01-04T13:01:56+08:00",
"author" : [
{
🔗 "reference" : "Organization/DMS-Org1"
},
{
🔗 "reference" : "Organization/DMS-Org6"
},
{
🔗 "reference" : "Organization/DMS-Org22"
},
{
🔗 "reference" : "Practitioner/DMS-Pra23"
}
],
"title" : "出院病摘",
"custodian" : {
🔗 "reference" : "Organization/DMS-Org1"
},
"section" : [
{
"title" : "出院病摘中的出院指示",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8653-8"
}
]
},
"entry" : [
{
🔗 "reference" : "CarePlan/DMS-Care5"
}
]
},
{
"title" : "出院病摘中的住院臆斷",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "46241-6"
}
]
},
"entry" : [
{
🔗 "reference" : "Observation/DMS-Obs7"
}
]
},
{
"title" : "出院病摘中的出院診斷",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11535-2"
}
]
},
"entry" : [
{
🔗 "reference" : "Condition/DMS-Con8"
}
]
},
{
"title" : "出院病摘中的癌症期別",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "22037-6"
}
]
},
"entry" : [
{
🔗 "reference" : "Observation/DMS-Obs9"
}
]
},
{
"title" : "出院病摘中的主訴",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10154-3"
}
]
},
"entry" : [
{
🔗 "reference" : "Condition/DMS-Con10"
}
]
},
{
"title" : "出院病摘中的病史",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10164-2"
}
]
},
"entry" : [
{
🔗 "reference" : "Observation/DMS-Obs11"
}
]
},
{
"title" : "出院病摘中的家族圖譜",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "74027-4"
}
]
},
"entry" : [
{
🔗 "reference" : "Media/DMS-Med12"
}
]
},
{
"title" : "出院病摘中的理學檢查發現",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29545-1"
}
]
},
"entry" : [
{
🔗 "reference" : "Observation/DMS-Obs13"
}
]
},
{
"title" : "出院病摘中的檢驗",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "30954-2"
}
]
},
"entry" : [
{
🔗 "reference" : "Observation/DMS-Obs14"
}
]
},
{
"title" : "出院病摘中的特殊檢查",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "19146-0"
}
]
},
"entry" : [
{
🔗 "reference" : "Observation/DMS-Obs15"
}
]
},
{
"title" : "出院病摘中的醫學影像檢查(ImageingStudy)",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "19005-8"
}
]
},
"entry" : [
{
🔗 "reference" : "ImagingStudy/DMS-Img16"
},
{
🔗 "reference" : "Media/DMS-Med17"
}
]
},
{
"title" : "出院病摘中的病理報告",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "22034-3"
}
]
},
"entry" : [
{
🔗 "reference" : "Observation/DMS-Obs18"
}
]
},
{
"title" : "出院病摘中的手術日期及方法",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8724-7"
}
]
},
"entry" : [
{
🔗 "reference" : "Procedure/DMS-Pro19"
}
]
},
{
"title" : "出院病摘中的住院治療經過",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8648-8"
}
]
},
"entry" : [
{
🔗 "reference" : "Procedure/DMS-Pro20"
},
{
🔗 "reference" : "Location/DMS-Loc4"
}
]
},
{
"title" : "出院病摘中的合併症與併發症",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "55109-3"
}
]
},
"entry" : [
{
🔗 "reference" : "Condition/DMS-Con21"
}
]
}
]
}