臺灣核心實作指引(TW Core IG)
0.3.1 - Trial Use
臺灣核心實作指引(TW Core IG)
0.3.1 - Trial Use
This page is part of the 臺灣核心實作指引(TW Core IG) (v0.3.1: Releases) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
<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>