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

: 手術摘要報告 - XML Representation

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<Composition xmlns="http://hl7.org/fhir">
  <id value="com-surgery-example"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><h3><b>手術摘要報告</b></h3><p><b>臨床狀態</b>：Final <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://hl7.org/fhir/composition-status">CompositionStatus</a>#final)</span></p><p><b>種類</b>：Medical records <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="https://loinc.org/">LOINC</a>#11503-0)</span></p><p><b>分類</b>：Surgical operation note <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="https://loinc.org/">LOINC</a>#11504-8)</span></p><p><b>病人</b>：<a href="Patient-pat-example.html">Patient/pat-example</a> "陳加玲"</p><p><b>編輯時間</b>：2023-11-05T14:45:00</p><p><b>報告創建者</b>：<a href="Practitioner-pra-dr-example.html">Practitioner/pra-dr-example</a> "王依昇"</p><p><b>根據特定技術領域的定義</b>：normal <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="http://terminology.hl7.org/CodeSystem/v3-Confidentiality/">v3 Code System Confidentiality</a>#N)</span></p><p><b>證明準確性</b>：</p><blockquote><p><b>認證者提供的認證類型</b>：Personal <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="http://hl7.org/fhir/composition-attestation-mode/">CompositionAttestationMode</a>#personal)</span></p><p><b>被證明的時間</b>：2023-11-05T15:30:00</p><p><b>負責證明的人員</b>：<a href="Practitioner-pra-dr-example.html">Practitioner/pra-dr-example</a> "王依昇"</p><p><b>負責維護機構</b>：<a href="Organization-org-hosp-example.html">Organization/org-hosp-example</a> "衛生福利部臺北醫院"</p></blockquote><p><b>正在記錄的臨床服務</b>：</p><blockquote><p><b>被記錄的主要臨床行為代碼</b>：Surgical <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="http://terminology.hl7.org/CodeSystem/v3-ActCode/">ActCode</a>#SURG)</span></p><p><b>文件所涵蓋的時間區間</b>：2023-11-05T12:00:00 ～ 2023-11-05T16:00:00</p></blockquote><p><b>報告小節內容：</b> <a href="Procedure-pro-appendectomy-example.html">Procedure/pro-appendectomy-example</a></p></div>
  </text>
  <status value="final"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="11503-0"/>
      <display value="Medical records"/>
    </coding>
  </type>
  <category>
    <coding>
      <system value="http://loinc.org"/>
      <code value="11504-8"/>
    </coding>
  </category>
  <subject>🔗 
    <reference value="Patient/pat-example"/>
  </subject>
  <date value="2023-11-05T14:45:00Z"/>
  <author>🔗 
    <reference value="Practitioner/pra-dr-example"/>
    <display value="王依昇"/>
  </author>
  <title value="手術摘要報告"/>
  <confidentiality value="N"/>
  <attester>
    <mode value="personal"/>
    <time value="2023-11-05T15:30:00Z"/>
    <party>🔗 
      <reference value="Practitioner/pra-dr-example"/>
      <display value="王依昇"/>
    </party>
  </attester>
  <custodian>🔗 
    <reference value="Organization/org-hosp-example"/>
    <display value="衛生福利部臺北醫院"/>
  </custodian>
  <event>
    <code>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
        <code value="SURG"/>
        <display value="Surgical"/>
      </coding>
    </code>
    <period>
      <start value="2023-11-05T12:00:00Z"/>
      <end value="2023-11-05T16:00:00Z"/>
    </period>
  </event>
  <section>
    <entry>🔗 
      <reference value="Procedure/pro-appendectomy-example"/>
    </entry>
  </section>
</Composition>