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

This page is part of the 臺灣核心實作指引(TW Core IG) (v0.2.2: 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

: 藥物過敏或不耐症 - XML Representation

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<AllergyIntolerance xmlns="http://hl7.org/fhir">
  <id value="all-medication-example"/>
  <meta>
    <profile
             value="https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/AllergyIntolerance-twcore"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><h3><b>藥物過敏</b></h3><p><b>臨床狀態</b>:Active <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical">AllergyIntoleranceClinicalStatusCodes</a>#active)</span></p><p><b>驗證狀態</b>:Confirmed <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="http://terminology.hl7.org/CodeSystem/allergyintolerance-verification">AllergyIntoleranceVerificationStatusCodes</a>#confirmed)</span></p><p><b>根本原因或運作機制</b>:Allergy <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="http://hl7.org/fhir/allergy-intolerance-type">AllergyIntoleranceType</a>#allergy)</span></p><p><b>確定的物質的類別</b>:Medication <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="http://hl7.org/fhir/allergy-intolerance-category">AllergyIntoleranceCategory</a>#medication)</span></p><p><b>嚴重程度</b>:High Risk <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="http://hl7.org/fhir/allergy-intolerance-criticality">AllergyIntoleranceCriticality</a>#high)</span></p><p><b>過敏或不耐症的識別</b>:青黴素過敏(Penicillin allergy) <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="http://snomed.info/sct">SNOMED CT</a>#91936005)</span></p><p><b>過敏或不耐症被識別的時間</b>:2023-10-15T08:45:00</p><p><b>病人</b>:<a href="Patient-pat-example.html">Patient/pat-example</a> "陳加玲"</p><p><b>紀錄者</b>:<a href="Practitioner-pra-dr-example.html">Practitioner/pra-dr-example</a> "王依昇"</p><p><b>被記錄的日期</b>:2023-10-15T12:00:00</p><p><b>關於過敏的資訊來源</b>:<a href="Practitioner-pra-nurse-example.html">Practitioner/pra-nurse-example</a> "陳莉"</p><p><b>最後一次已知反應發生的日期與時間</b>:2023-12-05T15:30:00</p><p><b>過敏或不耐受物質的不良反應紀錄</b>:</p><blockquote><p><b>過敏產生的特定物質或醫藥產品</b>:青黴素(Medicinal product containing penicillin and acting as antibacterial agent (product)) <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="http://snomed.info/sct">SNOMED CT</a>#6369005)</span></p><p><b>與此事件相關的臨床症狀/體徵)</b>:Upper respiratory tract hypersensitivity reaction <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="http://snomed.info/sct">SNOMED CT</a>#490008)</span></p><p><b>對整個過敏事件的描述</b>:呼吸急促、皮膚發紅</p><p><b>嚴重程度</b>:Severe <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="http://hl7.org/fhir/reaction-event-severity">AllergyIntoleranceSeverity</a>#severe)</span></p><p><b>如何接觸到該物質</b>:口服(Oral use) <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="http://snomed.info/sct">SNOMED CT</a>#26643006)</span></p><p><b>備註</b>:患者在服用青黴素後出現呼吸急促和皮膚發紅,症狀於2023年10月15日中午12:00發作</p></blockquote></div>
  </text>
  <clinicalStatus>
    <coding>
      <system
              value="http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical"/>
      <code value="active"/>
      <display value="Active"/>
    </coding>
    <text value="Active"/>
  </clinicalStatus>
  <verificationStatus>
    <coding>
      <system
              value="http://terminology.hl7.org/CodeSystem/allergyintolerance-verification"/>
      <code value="confirmed"/>
      <display value="Confirmed"/>
    </coding>
    <text value="Confirmed"/>
  </verificationStatus>
  <type value="allergy"/>
  <category value="medication"/>
  <criticality value="high"/>
  <code>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="91936005"/>
      <display value="Penicillin allergy"/>
    </coding>
    <text value="青黴素過敏"/>
  </code>
  <patient>🔗 
    <reference value="Patient/pat-example"/>
    <display value="陳加玲"/>
  </patient>
  <onsetDateTime value="2023-10-15T08:45:00Z"/>
  <recordedDate value="2023-10-15T12:00:00Z"/>
  <recorder>🔗 
    <reference value="Practitioner/pra-dr-example"/>
    <display value="王依昇"/>
  </recorder>
  <asserter>🔗 
    <reference value="Practitioner/pra-nurse-example"/>
    <display value="陳莉"/>
  </asserter>
  <lastOccurrence value="2023-10-15T12:00:00Z"/>
  <note>
    <text value="患者對青黴素過敏,可能導致呼吸急促、皮膚發紅"/>
  </note>
  <reaction>
    <substance>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="6369005"/>
        <display
                 value="Medicinal product containing penicillin and acting as antibacterial agent (product)"/>
      </coding>
      <text value="青黴素"/>
    </substance>
    <manifestation>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="490008"/>
        <display value="Upper respiratory tract hypersensitivity reaction"/>
      </coding>
    </manifestation>
    <description value="呼吸急促、皮膚發紅"/>
    <severity value="severe"/>
    <exposureRoute>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="26643006"/>
        <display value="Oral use"/>
      </coding>
      <text value="口服"/>
    </exposureRoute>
    <note>
      <text value="患者在服用青黴素後出現呼吸急促和皮膚發紅,症狀於2023年10月15日中午12:00發作"/>
    </note>
  </reaction>
</AllergyIntolerance>