臺灣核心實作指引(TW Core IG)
0.2.0 - Trial Use

This page is part of the 臺灣核心實作指引(TW Core 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 Composition: 陳加玲的病摘

陳加玲的病摘

臨床狀態:Final (CompositionStatus#final)

種類:Medical records ( LOINC#11503-0)

分類: Hospital Admission history and physical note ( LOINC#47039-3)

病人Patient/pat-example "陳加玲"

編輯時間:2023-09-10T10:30:00

病摘創建者Practitioner/pra-dr-example "王依昇"

根據特定技術領域的定義:restricted ( v3 Code System Confidentiality#R)

證明準確性

認證者提供的認證類型:Personal ( CompositionAttestationMode#personal)

被證明的時間:2023-09-10T11:00:00

負責證明的人員Practitioner/pra-dr-example "王依昇"

負責維護機構Organization/org-hosp-example "衛生福利部臺北醫院"

正在記錄的臨床服務

被記錄的主要臨床行為代碼:medication list ( ActCode#MEDLIST)

文件所涵蓋的時間區間:2023-09-10T08:00:00 ~ 2023-09-15T09:30:00

病摘小節內容:

section.entry[Observation]Observation/obs-bloodPressure-example

section.entry[Practitioner]Practitioner/pra-dr-example

section.entry[MedicationRequest]MedicationRequest/med-req-cod-example