電子病歷交換單張實作指引(EMR-IG)
0.2.0 - ci-build

This page is part of the 電子病歷交換單張實作指引(EMR-IG) (v0.2.0: 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

Example Bundle: 出院病摘 Bundle example

Document Details

Generated Narrative: Bundle 出院病摘

Document Subject

Unable to resolve subject ''

Document Content

出院病摘中的出院指示

出院病摘中的住院臆斷

出院病摘中的出院診斷

出院病摘中的癌症期別

出院病摘中的主訴

出院病摘中的病史

出院病摘中的家族圖譜

出院病摘中的理學檢查發現

出院病摘中的檢驗

出院病摘中的特殊檢查

出院病摘中的醫學影像檢查(ImageingStudy)

出院病摘中的病理報告

出院病摘中的手術日期及方法

出院病摘中的住院治療經過

出院病摘中的合併症與併發症

Additional Resources Included in Document

Entry 1 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Composition/DMS-Com24

Resource Composition:

Generated Narrative: Composition DMS-Com24

status: Final

type: 出院病摘

encounter: 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

date: 2023-01-04 13:01:56+0800

author:

title: 出院病摘

custodian: Organization 國立臺灣大學醫學院附設醫院

Entry 2 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Organization/DMS-Org1

Resource Organization:

Generated Narrative: Organization DMS-Org1

identifier: 0401180014

name: 國立臺灣大學醫學院附設醫院

Entry 3 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Patient/DMS-Pat2

Resource Patient:

Generated Narrative: Patient DMS-Pat2

黃睿駿 Male, DoB: 1999-01-01 ( Medical record number: 3djnjkndxksnx (use: official, ))

Active:true
Other Id:National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code/A123456789 (use: official, )

Entry 4 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Encounter/DMS-Enc3

Resource Encounter:

Generated Narrative: Encounter DMS-Enc3

status: completed

class: inpatient encounter

serviceType: No display for Encounter.serviceType (concept: General surgery (qualifier value))

subject: 黃睿駿 Male, DoB: 1999-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

participant

Diagnoses

-ConditionUse
*No display for Encounter.diagnosis.condition (reference: ->Condition )Chief complaint

Locations

-Location
*Location 病床

Entry 5 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Location/DMS-Loc4

Resource Location:

Generated Narrative: Location DMS-Loc4

identifier: Bed01

name: 病床

Entry 6 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/CarePlan/DMS-Care5

Resource CarePlan:

Generated Narrative: CarePlan DMS-Care5

status: Active

intent: Proposal

category: Hospital Discharge instructions

description: 出院指示

subject: 黃睿駿 Male, DoB: 1999-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

Entry 7 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Organization/DMS-Org6

Resource Organization:

Generated Narrative: Organization DMS-Org6

identifier: 8791831

name: 轉入醫事機構名稱

Entry 8 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Observation/DMS-Obs7

Resource Observation:

Generated Narrative: Observation DMS-Obs7

status: Final

code: 住院臆斷

subject: 黃睿駿 Male, DoB: 1999-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

effective: 2023-10-01 16:52:00+0800

performer: Practitioner 賴一施

value: 有軌電車乘客在交通意外事故中與機動車輛碰撞時受傷之初期照護

Entry 9 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Condition/DMS-Con8

Resource Condition:

Generated Narrative: Condition DMS-Con8

clinicalStatus: 出院診斷

category: 出院診斷

code: 結核病(Tuberculosis)

subject: 黃睿駿 Male, DoB: 1999-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

Entry 10 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Observation/DMS-Obs9

Resource Observation:

Generated Narrative: Observation DMS-Obs9

status: Final

code: 癌症期別

subject: 黃睿駿 Male, DoB: 1999-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

effective: 2023-10-01 16:52:00+0800

performer: Practitioner 賴一施

value: 第二期

Entry 11 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Condition/DMS-Con10

Resource Condition:

Generated Narrative: Condition DMS-Con10

clinicalStatus: 主訴

category: 主訴

code: 2小時前開始出現伴隨噁心的激烈心窩部疼痛。

subject: 黃睿駿 Male, DoB: 1999-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

Entry 12 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Observation/DMS-Obs11

Resource Observation:

Generated Narrative: Observation DMS-Obs11

status: Final

code: 病史

subject: 黃睿駿 Male, DoB: 1999-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

effective: 2023-10-01 16:52:00+0800

performer: Practitioner 賴一施

value: 病人左側胸部曾受到壓傷。

Entry 13 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Media/DMS-Med12

Resource DocumentReference:

Generated Narrative: DocumentReference DMS-Med12

Entry 14 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Observation/DMS-Obs13

Resource Observation:

Generated Narrative: Observation DMS-Obs13

status: Final

code: 理學檢查發現

subject: 黃睿駿 Male, DoB: 1999-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

effective: 2023-10-01 16:52:00+0800

performer: Practitioner 賴一施

value: 皮膚與口腔粘膜蒼白，其餘身體檢查無明顯異常。

Entry 15 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Observation/DMS-Obs14

Resource Observation:

Generated Narrative: Observation DMS-Obs14

status: Final

code: Glucose blood

subject: 黃睿駿 Male, DoB: 1999-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

effective: 2023-10-01 16:52:00+0800

performer: Practitioner 賴一施

value: 60~85mg/dL

Entry 16 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Observation/DMS-Obs15

Resource Observation:

Generated Narrative: Observation DMS-Obs15

status: Final

code: 心電圖

subject: 黃睿駿 Male, DoB: 1999-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

effective: 2023-10-01 16:52:00+0800

performer: Practitioner 賴一施

value: 心律不整

Entry 17 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/ImagingStudy/DMS-Img16

Resource ImagingStudy:

Generated Narrative: ImagingStudy DMS-Img16

status: Available

subject: 黃睿駿 Male, DoB: 1999-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

started: 2023-08-21 00:00:00+0800

referrer: Practitioner 賴一施

Series

-UidModalityBodySite
*1X光No display for ImagingStudy.series.bodySite (concept: 胸部)

Entry 18 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Media/DMS-Med17

Resource DocumentReference:

Generated Narrative: DocumentReference DMS-Med17

Entry 19 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Observation/DMS-Obs18

Resource Observation:

Generated Narrative: Observation DMS-Obs18

status: Final

code: 病理報告

subject: 黃睿駿 Male, DoB: 1999-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

effective: 2023-10-01 16:52:00+0800

performer: Practitioner 賴一施

value: 肌肉活組織切片標本的顯微鏡檢查顯示骨骼細胞的脂肪浸潤與退化性變化。

Entry 20 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Procedure/DMS-Pro19

Resource Procedure:

Generated Narrative: Procedure DMS-Pro19

status: Completed

category: Surgical operation note description Narrative

code: 選擇右肋緣下1 cm（或以膽囊三角體表投影處選擇斜切口），做平行於肋弓的斜切口，切口長約4～6 cm， 切開腹直肌前鞘，進腹腔先結紮膽囊動脈和膽囊管，後以電刀或剪刀自膽囊底部分離膽囊至膽囊管，切斷膽囊管去膽囊，將膽囊管殘端雙重結紮。

subject: 黃睿駿 Male, DoB: 1999-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

Entry 21 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Procedure/DMS-Pro20

Resource Procedure:

Generated Narrative: Procedure DMS-Pro20

status: Completed

category: Hospital course Narrative

code: 子宮超音波

subject: 黃睿駿 Male, DoB: 1999-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

note: 未確認流感病毒所致流行性感冒併明示類型肺炎

Entry 22 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Condition/DMS-Con21

Resource Condition:

Generated Narrative: Condition DMS-Con21

clinicalStatus: 治癒出院

category: 合併症與併發症

code: 有發燒現象、無併發症

subject: 黃睿駿 Male, DoB: 1999-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))

Entry 23 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Organization/DMS-Org22

Resource Organization:

Generated Narrative: Organization DMS-Org22

identifier: 0601160016

name: 轉出醫事機構名稱

Entry 24 - fullUrl = https://twcore.mohw.gov.tw/ig/emr/Practitioner/DMS-Pra23

Resource Practitioner:

Generated Narrative: Practitioner DMS-Pra23

identifier: National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code/A123456789 (use: official, )

name: 賴一施