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

This page is part of the 臺灣核心實作指引(TW Core IG) (v0.2.1: 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 - JSON Representation

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{
  "resourceType" : "Composition",
  "id" : "com-surgery-example",
  "text" : {
    "status" : "generated",
    "div" : "<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>"
  },
  "status" : "final",
  "type" : {
    "coding" : [
      {
        "system" : "http://loinc.org",
        "code" : "11503-0",
        "display" : "Medical records"
      }
    ]
  },
  "category" : [
    {
      "coding" : [
        {
          "system" : "http://loinc.org",
          "code" : "11504-8"
        }
      ]
    }
  ],
  "subject" : {
    🔗 "reference" : "Patient/pat-example"
  },
  "date" : "2023-11-05T14:45:00Z",
  "author" : [
    {
      🔗 "reference" : "Practitioner/pra-dr-example",
      "display" : "王依昇"
    }
  ],
  "title" : "手術摘要報告",
  "confidentiality" : "N",
  "attester" : [
    {
      "mode" : "personal",
      "time" : "2023-11-05T15:30:00Z",
      "party" : {
        🔗 "reference" : "Practitioner/pra-dr-example",
        "display" : "王依昇"
      }
    }
  ],
  "custodian" : {
    🔗 "reference" : "Organization/org-hosp-example",
    "display" : "衛生福利部臺北醫院"
  },
  "event" : [
    {
      "code" : [
        {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
              "code" : "SURG",
              "display" : "Surgical"
            }
          ]
        }
      ],
      "period" : {
        "start" : "2023-11-05T12:00:00Z",
        "end" : "2023-11-05T16:00:00Z"
      }
    }
  ],
  "section" : [
    {
      "entry" : [
        {
          🔗 "reference" : "Procedure/pro-appendectomy-example"
        }
      ]
    }
  ]
}