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

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: 門診病歷 Composition example - XML Representation

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<Composition xmlns="http://hl7.org/fhir">
  <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"><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>
  </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>