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" : "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\"><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"
}
]
}
]
}