電子病歷交換單張實作指引(EMR-IG)
0.1.0 - ci-build

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: 門診病歷 Composition example - JSON Representation

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{
  "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 --&gt; (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"
        }
      ]
    }
  ]
}