Additional Resources Included in Document

Entry 1 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Composition/CompositionDischargeSummary-min

Resource Composition:

出院病例摘要

狀態：Final (CompositionStatus#final)

種類：Discharge summary ( LOINC#18842-5)

病人：Patient/Patient-min "安格斯"

就醫事件：Encounter/Encounter-min

文件產生時間：2024-05-12T14:30:00

文件創建單位：Organization/OrganizationHosp-min "國泰醫療財團法人國泰綜合醫院"

文件創建者：Practitioner/Practitioner-min "劉伊詩"

出院病摘小節內容：

section[Impression]： Observation/ObservationImpression-min

section[DischargeDiagnosis]： Condition/ConditionDischargeDiagnosis-min

section[CancerStaging]： Observation/ObservationCancerStaging-min

section[ChiefComplaint]： Condition/ConditionChiefComplaint-min

section[PresentIllness]： Condition/ConditionPresentIllness-min

section[PhysicalExamination]： Observation/ObservationPhysicalExamination-min

section[LaboratoryData]： Observation/ObservationLaboratory-min
section[LaboratoryData]： Observation/ObservationLaboratory-lab

section[ImagingStudy]： ImagingStudy/ImagingStudy-min

section[PathologyReport]： Observation/ObservationPathologyReport-min

section[SurgicalMethod]： Procedure/Procedure-min

section[HospitalCourse]： Procedure/ProcedureHospitalCourse-min
section[HospitalCourse]： Location/Location-min

section[ComorbiditesAndOrComlications]： Condition/ConditionComorbiditiesandComplications-min

section[InstructionsOnDischarge]： CarePlan/CarePlan-min
section[InstructionsOnDischarge]： MedicationRequest/MedicationRequest-min

Entry 2 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Patient/Patient-min

Resource Patient:

病人基本資料

識別碼型別：National Person Identifier （ Identifier Type Codes#NNxxx [extension: Identifier Suffix]：TWN）
身分證字號（official）A123456789 （http://www.moi.gov.tw）

識別碼型別：Medical record number （ Identifier Type Codes#MR）
病歷號（official）：70892114 （https://www.cgh.org.tw）

姓名（official）：安格斯

性別：Male ( AdministrativeGender#male)

出生日期：2000-02-02

Entry 3 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Organization/OrganizationHosp-min

Resource Organization:

醫事機構基本資料

機構名稱：國泰醫療財團法人國泰綜合醫院

識別碼型別：Provider number（ IdentifierType#PRN）
機構代碼（official）：1101020018 (https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/organization-identifier-tw)

機構種類：Healthcare Provider ( OrganizationType#prov)

Entry 4 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Practitioner/Practitioner-min

Resource Practitioner:

醫師基本資料

姓名（official）：劉伊詩

Entry 5 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Encounter/Encounter-min

Resource Encounter:

就醫資料

就醫現況：Finished

就醫分類：pre-admission ( ActEncounterCode#PRENC)

出院科別：Colorectal Surgery ( SNOMED CT#408464004)

病人：Patient/Patient-min "安格斯"

出院狀況：改門診治療

出院床號：Location/Location-min "4012S"

醫師：Practitioner/Practitioner-min "劉伊詩"

住院日期：2023-09-06 17:00:14-0800

出院日期：2023-09-12 18:00:14-0800

Entry 6 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Location/Location-min

Resource Location:

出院床號

出院床號：4012S

地點名稱：病床

Entry 7 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Observation/ObservationImpression-min

Resource Observation:

住院臆斷

分類：Hospital admission diagnosis Narrative - Reported ( LOINC Codes#46241-6)

住院臆斷狀態：Preliminary ( ObservationStatus#preliminary)

住院臆斷項目：Physical findings of Hemorrhoid ( LOINC臨床分類值集#32438-4)

住院臆斷：Prolapsed mixed hemorrhoids

病人：Patient/Patient-min "安格斯"

檢驗日期：2023-09-07

Entry 8 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Condition/ConditionDischargeDiagnosis-min

Resource Condition:

出院診斷

臨床狀態：Remission ( ConditionClinicalStatusCodes#remission)

病情、問題或診斷分類：Hospital discharge Dx Narrative ( Condition Category Codes#11535-2)

病人：Patient/Patient-min "安格斯"

就醫事件：Encounter/Encounter-min

出院診斷：Prolapsed hemorrhoids, Gr. III s/p laser hemorrhoidoplasty + partial hemorrhoidectomy ( 臺灣2021年中文版ICD-10-CM#K64.4)

出院診斷日期：2023-09-07 10:00:14-0800

Entry 9 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Observation/ObservationCancerStaging-min

Resource Observation:

癌症期別

分類：Staging Cancer Narrative ( LOINC Codes#22037-6)

癌症期別狀態：Final ( ObservationStatus#final)

癌症期別代碼：Clinical TNM stage grouping ( mCode Cancer Stage Type#399537006)

病人：Patient/Patient-min "安格斯"

癌症期別：American Joint Committee on Cancer stage IIIC (qualifier value) ( mCode Cancer Stage Type#1222806003)

檢驗日期：2024-04-01

Entry 10 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Condition/ConditionChiefComplaint-min

Resource Condition:

病人主訴

臨床狀態：Active ( ConditionClinicalStatusCodes#active)

病情、問題或診斷分類：Chief complaint Narrative - Reported ( Condition Category Codes#10154-3)

病人：Patient/Patient-min "安格斯"

就醫事件：Encounter/Encounter-min

病人主訴之病情識別：肛門及直腸出血 ( 臺灣2021年中文版ICD-10-CM#K62.5)

病人主訴：Anal pain with anal bleeding for few days

Entry 11 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Condition/ConditionPresentIllness-min

Resource Condition:

病史

臨床狀態：Remission ( ConditionClinicalStatusCodes#remission)

病情、問題或診斷分類：Complications Document ( Condition Category Codes#55109-3)

病人：Patient/Patient-min "安格斯"

就醫事件：Encounter/Encounter-min

病史：肺結核 ( 臺灣2021年中文版ICD-10-CM#A15.0)

Entry 12 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Observation/ObservationPhysicalExamination-min

Resource Observation:

理學檢查發現

分類：Exam ( Observation Category Codes#exam)

理學檢查發現狀態：Final ( ObservationStatus#final)

理學檢查發現項目：Inspection of mouth ( SNOMED CT體檢值集#39868003)

理學檢查發現結果：oral lesion: No

病人：Patient/Patient-min "安格斯"

檢驗日期：2023-09-07

Entry 13 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Observation/ObservationLaboratory-min

Resource Observation:

檢驗／特殊檢查

檢驗／特殊檢查種類：特殊檢查

特殊檢查狀態：Final ( ObservationStatus#final)

特殊檢查：心電圖(EKG)

特殊檢查結果：Normal sinus rhythmwith sinus arrhythmia Voltage criteria for left ventricular hypertrophy Early repolarization

病人：Patient/Patient-min "安格斯"

檢驗日期：2023-09-07

Entry 14 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Observation/ObservationLaboratory-lab

Resource Observation:

檢驗／特殊檢查

分類：Relevant diagnostic tests/laboratory data Narrative ( LOINC Codes#30954-2)

檢驗狀態：Final ( ObservationStatus#final)

檢驗：血色素檢查 ( 臺灣醫療服務給付項目#08003C)

檢驗值：15.9 g/dL

病人：Patient/Patient-min "安格斯"

檢驗日期：2023-09-06

Entry 15 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/ImagingStudy/ImagingStudy-min

Resource ImagingStudy:

醫療影像檢查

醫療影像檢查狀態：Available ( ImagingStudyStatus#available)

病人：Patient/Patient-min "安格斯"

就醫事件：Encounter/Encounter-min

醫療影像檢查開始時間：2023-09-07 11:01:20-0300

醫療影像檢查解讀者：Practitioner/Practitioner-min "劉伊詩"

醫療影像檢查敘述：No significant ro entgenological abnormality is observed.

Entry 16 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Observation/ObservationPathologyReport-min

Resource Observation:

病理報告

分類：Pathology report Cancer Narrative ( LOINC Codes#22034-3)

病理報告狀態：Final ( ObservationStatus#final)

病理報告項目：Anus, hemorrhoidectomy, hemorrhoid.

病理報告結果：The specimen submitted consists of 2 pieces of anal tissue measuring 1.4 cm in greatest dimension. Al1 for section. Microscopically, the section shows a picture of hemorrhoid, composed of dilated,tortuous and congested veins in the stroma of the anal mucosa

病人：Patient/Patient-min "安格斯"

檢驗日期：2023-09-08

病理報告負責者：Practitioner/Practitioner-min "劉伊詩"

Entry 17 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Procedure/Procedure-min

Resource Procedure:

處置/手術

處置/手術狀態：Completed ( EventStatus#completed)

處置/手術種類：Surgical operation note description Narrative ( LOINC#8724-7)

處置/手術的識別碼：開放性痔靜脈叢部分切除術 ( 臺灣2021年中文版ICD-10-PCS#06BY0ZC)

病人：Patient/Patient-min "安格斯"

就醫事件：Encounter/Encounter-min

處置/手術日期：2023-09-08 11:25:11-08:00

Entry 18 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Procedure/ProcedureHospitalCourse-min

Resource Procedure:

住院治療經過

住院治療經過狀態：Completed ( EventStatus#completed)

住院治療經過種類：Hospital course Narrative ( LOINC#8648-8)

住院治療經過代碼：Hospital course Narrative ( LOINC#8648-8)

病人：Patient/Patient-min "安格斯"

就醫事件：Encounter/Encounter-min

住院治療經過：After admission, prepare operation work-up was done. The surgical method of laparoscopic cholecystectomy was done on 10/20/2023. Post operative wound pain could tolerance under analgesic drug. During the hospitalization, vital signs were stable, post operative wound appeared: no oozing, no redness or other infection signs were noted, no tenderness. To education of wound care, discharge today and outpatient department follow up was arrange.

Entry 19 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Condition/ConditionComorbiditiesandComplications-min

Resource Condition:

合併症與併發症

臨床狀態：Resolved ( ConditionClinicalStatusCodes#resolved)

病情、問題或診斷分類：解決 ( Condition Category Codes#55109-3)

病人：Patient/Patient-min "安格斯"

就醫事件：Encounter/Encounter-min

合併症與併發症：術中及術後併發症及肌肉骨骼系統疾患，他處未歸類者 ( 臺灣2021年中文版ICD-10-CM#M96)

合併症與併發症診斷日期：2023-09-07 10:00:14-0800

Entry 20 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/CarePlan/CarePlan-min

Resource CarePlan:

出院指示

狀態：Completed ( RequestStatus#completed)

類別：Proposal ( Care Plan Intent#proposal)

病人：Patient/Patient-min "安格斯"

就醫事件：Encounter/Encounter-min

出院指示：出院指示

出院指示藥物：MedicationRequest/MedicationRequest-min

Entry 21 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/MedicationRequest/MedicationRequest-min

Resource MedicationRequest:

藥品請求

藥品請求的狀態：Active ( MedicationRequest Status Reason Codes#active)

藥品請求的意圖：Proposal ( medicationRequest Intent#proposal)

開立的藥品：ASPIRIN TABLETS 500MG "S.Y." ( 臺灣健保用藥品項#A003092100)

病人：Patient/Patient-min "安格斯"

就醫事件：Encounter/Encounter-min

提出藥品請求請求者：Practitioner/Practitioner-min"劉伊詩"

給藥執行者：Practitioner/Practitioner-min"劉伊詩"

開立處方的原因：CarePlan/CarePlan-min