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

Example Composition: 手術摘要報告

手術摘要報告

臨床狀態:Final (CompositionStatus#final)

種類:Medical records ( LOINC#11503-0)

分類:Surgical operation note ( LOINC#11504-8)

病人Patient/pat-example "陳加玲"

編輯時間:2023-11-05T14:45:00

報告創建者Practitioner/pra-dr-example "王依昇"

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

證明準確性

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

被證明的時間:2023-11-05T15:30:00

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:Surgical ( ActCode#SURG)

文件所涵蓋的時間區間:2023-11-05T12:00:00 ~ 2023-11-05T16:00:00

報告小節內容: Procedure/pro-appendectomy-example