醫查實作指引
0.1.0 - CI Build
醫查實作指引
0.1.0 - CI Build
醫查實作指引 - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>出院病例摘要</b></h3><p><b>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>：Discharge summary <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"https://loinc.org/\">LOINC</a>#18842-5)</span></p><p><b>病人</b>：<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>就醫事件</b>：<a href=\"Encounter-Encounter-min.html\">Encounter/Encounter-min</a></p><p><b>文件產生時間</b>：2024-05-12T14:30:00</p><p><b>文件創建單位</b>：<a href=\"Organization-OrganizationHosp-min.html\">Organization/OrganizationHosp-min</a> \"國泰醫療財團法人國泰綜合醫院\"</p><p><b>文件創建者</b>：<a href=\"Practitioner-Practitioner-min.html\">Practitioner/Practitioner-min</a> \"劉伊詩\"</p><p><b>出院病摘小節內容：</b></p><blockquote><p><b>section[Impression]</b>： <a href=\"Observation-ObservationImpression-min.html\">Observation/ObservationImpression-min</a></p><p><b>section[DischargeDiagnosis]</b>： <a href=\"Condition-ConditionDischargeDiagnosis-min.html\">Condition/ConditionDischargeDiagnosis-min</a></p><p><b>section[CancerStaging]</b>： <a href=\"Observation-ObservationCancerStaging-min.html\">Observation/ObservationCancerStaging-min</a></p><p><b>section[ChiefComplaint]</b>： <a href=\"Condition-ConditionChiefComplaint-min.html\">Condition/ConditionChiefComplaint-min</a></p><p><b>section[PresentIllness]</b>： <a href=\"Condition-ConditionPresentIllness-min.html\">Condition/ConditionPresentIllness-min</a></p><p><b>section[PhysicalExamination]</b>： <a href=\"Observation-ObservationPhysicalExamination-min.html\">Observation/ObservationPhysicalExamination-min</a></p><p><b>section[LaboratoryData]</b>： <a href=\"Observation-ObservationLaboratory-min.html\">Observation/ObservationLaboratory-min</a><br/><b>section[LaboratoryData]</b>： <a href=\"Observation-ObservationLaboratory-lab.html\">Observation/ObservationLaboratory-lab</a></p><p><b>section[ImagingStudy]</b>： <a href=\"ImagingStudy-ImagingStudy-min.html\">ImagingStudy/ImagingStudy-min</a></p><p><b>section[PathologyReport]</b>： <a href=\"Observation-ObservationPathologyReport-min.html\">Observation/ObservationPathologyReport-min</a></p><p><b>section[SurgicalMethod]</b>： <a href=\"Procedure-Procedure-min.html\">Procedure/Procedure-min</a></p><p><b>section[HospitalCourse]</b>： <a href=\"Procedure-ProcedureHospitalCourse-min.html\">Procedure/ProcedureHospitalCourse-min</a><br/><b>section[HospitalCourse]</b>： <a href=\"Location-Location-min.html\">Location/Location-min</a></p><p><b>section[ComorbiditesAndOrComlications]</b>： <a href=\"Condition-ConditionComorbiditiesandComplications-min.html\">Condition/ConditionComorbiditiesandComplications-min</a></p><p><b>section[InstructionsOnDischarge]</b>： <a href=\"CarePlan-CarePlan-min.html\">CarePlan/CarePlan-min</a><br/><b>section[InstructionsOnDischarge]</b>： <a href=\"MedicationRequest-MedicationRequest-min.html\">MedicationRequest/MedicationRequest-min</a></p></blockquote></div>"
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"encounter" : {
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"date" : "2024-05-12T14:30:00+08:00",
"author" : [
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🔗 "reference" : "Organization/OrganizationHosp-min"
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🔗 "reference" : "Practitioner/Practitioner-min"
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"title" : "出院病歷摘要",
"section" : [
{
"title" : "住院臆斷",
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"entry" : [
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},
{
"title" : "出院診斷",
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"code" : "11535-2",
"display" : "Hospital discharge Dx Narrative"
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"entry" : [
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🔗 "reference" : "Condition/ConditionDischargeDiagnosis-min"
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},
{
"title" : "癌症期別",
"code" : {
"coding" : [
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"system" : "http://loinc.org",
"code" : "22037-6",
"display" : "Staging Cancer Narrative"
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{
"title" : "主訴",
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"coding" : [
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"code" : "10154-3",
"display" : "Chief complaint Narrative - Reported"
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]
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"entry" : [
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🔗 "reference" : "Condition/ConditionChiefComplaint-min"
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{
"title" : "病史",
"code" : {
"coding" : [
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"system" : "http://loinc.org",
"code" : "10164-2",
"display" : "History of Present illness Narrative"
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]
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"entry" : [
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🔗 "reference" : "Condition/ConditionPresentIllness-min"
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},
{
"title" : "理學檢查發現",
"code" : {
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{
"title" : "檢驗與特殊檢查",
"code" : {
"coding" : [
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"code" : "30954-2",
"display" : "Relevant diagnostic tests/laboratory data Narrative"
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"entry" : [
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🔗 "reference" : "Observation/ObservationLaboratory-min"
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🔗 "reference" : "Observation/ObservationLaboratory-lab"
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},
{
"title" : "醫療影像檢查",
"code" : {
"coding" : [
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"code" : "18748-4",
"display" : "Diagnostic imaging study"
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🔗 "reference" : "ImagingStudy/ImagingStudy-min"
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{
"title" : "病理報告",
"code" : {
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"display" : "Pathology report Cancer Narrative"
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{
"title" : "手術日期及方法",
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{
"title" : "住院治療經過",
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{
"title" : "合併症與併發症",
"code" : {
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"code" : "55109-3",
"display" : "Complications Document"
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🔗 "reference" : "Condition/ConditionComorbiditiesandComplications-min"
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{
"title" : "出院指示",
"code" : {
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"code" : "8653-8",
"display" : "Hospital Discharge instructions"
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]
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"entry" : [
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🔗 "reference" : "CarePlan/CarePlan-min"
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{
🔗 "reference" : "MedicationRequest/MedicationRequest-min"
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]
}
]
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},
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>病人基本資料</b></h3><blockquote><p><b>識別碼型別</b>：National Person Identifier <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">（ <a href=\"http://terminology.hl7.org/CodeSystem/v2-0203\">Identifier Type Codes</a>#NNxxx <b>[extension: <a href=\"https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/identifier-suffix\">Identifier Suffix</a>]：</b>TWN）</span><br/><b>身分證字號（official）</b>A123456789 （http://www.moi.gov.tw）</p></blockquote><blockquote><p><b>識別碼型別</b>：Medical record number <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">（ <a href=\"http://terminology.hl7.org/CodeSystem/v2-0203\">Identifier Type Codes</a>#MR）</span><br/><b>病歷號（official）</b>：70892114 （https://www.cgh.org.tw）</p></blockquote><p><b>姓名（official）</b>：安格斯</p><p><b>性別</b>：Male <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://hl7.org/fhir/R4/codesystem-administrative-gender.html\">AdministrativeGender</a>#male)</span></p><p><b>出生日期</b>：2000-02-02</p></div>"
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"system" : "http://www.moi.gov.tw",
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{
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"name" : [
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"use" : "usual",
"text" : "安格斯"
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],
"gender" : "male",
"birthDate" : "2000-02-02"
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},
{
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"resource" : {
"resourceType" : "Organization",
"id" : "OrganizationHosp-min",
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"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>醫事機構基本資料</b></h3><p><b>機構名稱</b>：國泰醫療財團法人國泰綜合醫院</p><p><b>識別碼型別</b>：Provider number<span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">（ <a href=\"http://terminology.hl7.org/CodeSystem/v2-0203\">IdentifierType</a>#PRN）</span><br/><b>機構代碼（official）</b>：1101020018 (https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/organization-identifier-tw)</p><p><b>機構種類</b>：Healthcare Provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://hl7.org/fhir/R4/codesystem-organization-type.html\">OrganizationType</a>#prov)</span></p></div>"
},
"identifier" : [
{
"use" : "official",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "PRN"
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]
},
"system" : "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/organization-identifier-tw",
"value" : "1101020018"
}
],
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/organization-type",
"code" : "prov"
}
]
}
],
"name" : "國泰醫療財團法人國泰綜合醫院"
}
},
{
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"resource" : {
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"id" : "Practitioner-min",
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"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>醫師基本資料</b></h3><p><b>姓名（official）</b>：劉伊詩</p></div>"
},
"name" : [
{
"use" : "official",
"text" : "劉伊詩"
}
]
}
},
{
"fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/Encounter/Encounter-min",
"resource" : {
"resourceType" : "Encounter",
"id" : "Encounter-min",
"meta" : {
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"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>就醫資料</b></h3><p><b>就醫現況</b>：Finished</p><p><b>就醫分類</b>：pre-admission <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"https://terminology.hl7.org/4.0.0/ValueSet-v3-ActEncounterCode.html\">ActEncounterCode</a>#PRENC)</span></p><p><b>出院科別</b>：Colorectal Surgery <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://snomed.info/sct\">SNOMED CT</a>#408464004)</span></p><p><b>病人</b>：<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>出院狀況</b>：改門診治療</p><p><b>出院床號</b>：<a href=\"Location-Location-min.html\">Location/Location-min</a> \"4012S\"</p><b>醫師</b>：<a href=\"Practitioner-Practitioner-min.html\">Practitioner/Practitioner-min</a> \"劉伊詩\"<p><b>住院日期</b>：2023-09-06 17:00:14-0800</p><p><b>出院日期</b>：2023-09-12 18:00:14-0800</p></div>"
},
"status" : "finished",
"class" : {
"system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"code" : "PRENC"
},
"serviceType" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "408464004",
"display" : "Colorectal Surgery"
}
]
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"subject" : {
🔗 "reference" : "Patient/Patient-min"
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"participant" : [
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"individual" : {
🔗 "reference" : "Practitioner/Practitioner-min"
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],
"period" : {
"start" : "2023-09-06T17:00:14+08:00",
"end" : "2023-09-12T18:00:14+08:00"
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"hospitalization" : {
"destination" : {
🔗 "reference" : "Location/Location-min"
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"dischargeDisposition" : {
"text" : "改門診治療"
}
}
}
},
{
"fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/Location/Location-min",
"resource" : {
"resourceType" : "Location",
"id" : "Location-min",
"meta" : {
"profile" : [
🔗 "https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/location-imri"
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},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>出院床號</b></h3><p><b>出院床號</b>：4012S</p><p><b>地點名稱</b>：病床</p></div>"
},
"identifier" : [
{
"value" : "4012S"
}
],
"name" : "病床"
}
},
{
"fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/Observation/ObservationImpression-min",
"resource" : {
"resourceType" : "Observation",
"id" : "ObservationImpression-min",
"meta" : {
"profile" : [
🔗 "https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/observation-impression-imri"
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},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>住院臆斷</b></h3><p><b>分類</b>：Hospital admission diagnosis Narrative - Reported <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://loinc.org\">LOINC Codes</a>#46241-6)</span></p><p><b>住院臆斷狀態</b>：Preliminary <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://hl7.org/fhir/observation-status\">ObservationStatus</a>#preliminary)</span></p><p><b>住院臆斷項目</b>：Physical findings of Hemorrhoid <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://loinc.orgs\">LOINC臨床分類值集</a>#32438-4)</span></p><p><b>住院臆斷</b>：Prolapsed mixed hemorrhoids</p><p><b>病人</b>：<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>檢驗日期</b>：2023-09-07</p></div>"
},
"status" : "preliminary",
"category" : [
{
"coding" : [
{
"system" : "http://loinc.org",
"code" : "46241-6",
"display" : "Hospital admission diagnosis Narrative - Reported"
}
]
}
],
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "32438-4",
"display" : "Physical findings of Hemorrhoid"
}
]
},
"subject" : {
🔗 "reference" : "Patient/Patient-min"
},
"effectiveDateTime" : "2023-09-07",
"valueString" : "Prolapsed mixed hemorrhoids"
}
},
{
"fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/Condition/ConditionDischargeDiagnosis-min",
"resource" : {
"resourceType" : "Condition",
"id" : "ConditionDischargeDiagnosis-min",
"meta" : {
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"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>出院診斷</b></h3><p><b>臨床狀態</b>：Remission <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://terminology.hl7.org/CodeSystem/condition-clinical\">ConditionClinicalStatusCodes</a>#remission)</span></p><p><b>病情、問題或診斷分類</b>：Hospital discharge Dx Narrative <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://loinc.org\">Condition Category Codes</a>#11535-2)</span></p><p><b>病人</b>：<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>就醫事件</b>：<a href=\"Encounter-Encounter-min.html\">Encounter/Encounter-min</a></p><p><b>出院診斷</b>：Prolapsed hemorrhoids, Gr. III s/p laser hemorrhoidoplasty + partial hemorrhoidectomy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2021-tw\">臺灣2021年中文版ICD-10-CM</a>#K64.4)</span></p><p><b>出院診斷日期</b>：2023-09-07 10:00:14-0800</p></div>"
},
"clinicalStatus" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/condition-clinical",
"code" : "remission",
"display" : "Remission"
}
]
},
"category" : [
{
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11535-2",
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]
}
],
"code" : {
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{
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"code" : "K64.4",
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}
],
"text" : "Prolapsed hemorrhoids, Gr. III s/p laser hemorrhoidoplasty + partial hemorrhoidectomy"
},
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},
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🔗 "reference" : "Encounter/Encounter-min"
},
"recordedDate" : "2023-09-07T10:00:14+08:00"
}
},
{
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},
"status" : "final",
"category" : [
{
"coding" : [
{
"system" : "http://loinc.org",
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}
],
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"coding" : [
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}
]
},
"subject" : {
🔗 "reference" : "Patient/Patient-min"
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{
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{
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}
]
}
}
},
{
"fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/Condition/ConditionChiefComplaint-min",
"resource" : {
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},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>病人主訴</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/condition-clinical\">ConditionClinicalStatusCodes</a>#active)</span></p><p><b>病情、問題或診斷分類</b>：Chief complaint Narrative - Reported <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://loinc.org\">Condition Category Codes</a>#10154-3)</span></p><p><b>病人</b>：<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>就醫事件</b>：<a href=\"Encounter-Encounter-min.html\">Encounter/Encounter-min</a></p><p><b>病人主訴之病情識別</b>：肛門及直腸出血 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2021-tw\">臺灣2021年中文版ICD-10-CM</a>#K62.5)</span></p><p><b>病人主訴</b>：Anal pain with anal bleeding for few days</p></div>"
},
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}
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"display" : "肛門及直腸出血"
}
],
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},
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🔗 "reference" : "Patient/Patient-min"
},
"encounter" : {
🔗 "reference" : "Encounter/Encounter-min"
},
"note" : [
{
"text" : "Anal pain with anal bleeding for few days"
}
]
}
},
{
"fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/Condition/ConditionPresentIllness-min",
"resource" : {
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"meta" : {
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},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>病史</b></h3><p><b>臨床狀態</b>：Remission <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://terminology.hl7.org/CodeSystem/condition-clinical\">ConditionClinicalStatusCodes</a>#remission)</span></p><p><b>病情、問題或診斷分類</b>：Complications Document <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://loinc.org\">Condition Category Codes</a>#55109-3)</span></p><p><b>病人</b>：<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>就醫事件</b>：<a href=\"Encounter-Encounter-min.html\">Encounter/Encounter-min</a></p><p><b>病史</b>：肺結核 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2021-tw\">臺灣2021年中文版ICD-10-CM</a>#A15.0)</span></p></div>"
},
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},
"category" : [
{
"coding" : [
{
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}
],
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"coding" : [
{
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}
]
},
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🔗 "reference" : "Patient/Patient-min"
},
"encounter" : {
🔗 "reference" : "Encounter/Encounter-min"
}
}
},
{
"fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/Observation/ObservationPhysicalExamination-min",
"resource" : {
"resourceType" : "Observation",
"id" : "ObservationPhysicalExamination-min",
"meta" : {
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},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>理學檢查發現</b></h3><p><b>分類</b>：Exam <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://terminology.hl7.org/CodeSystem/observation-category\">Observation Category Codes</a>#exam)</span></p><p><b>理學檢查發現狀態</b>：Final <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://hl7.org/fhir/observation-status\">ObservationStatus</a>#final)</span></p><p><b>理學檢查發現項目</b>：Inspection of mouth <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://snomed.info/sct\">SNOMED CT體檢值集</a>#39868003)</span></p><p><b>理學檢查發現結果</b>：oral lesion: No</p><p><b>病人</b>：<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>檢驗日期</b>：2023-09-07</p></div>"
},
"status" : "final",
"category" : [
{
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],
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}
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},
"subject" : {
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"effectiveDateTime" : "2023-09-07",
"valueString" : "oral lesion: No"
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},
{
"fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/Observation/ObservationLaboratory-min",
"resource" : {
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"meta" : {
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},
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"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>檢驗／特殊檢查</b></h3><p><b>檢驗／特殊檢查種類</b>：特殊檢查</p><p><b>特殊檢查狀態</b>：Final <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://hl7.org/fhir/observation-status\">ObservationStatus</a>#final)</span></p><p><b>特殊檢查</b>：心電圖(EKG)</p><p><b>特殊檢查結果</b>：Normal sinus rhythmwith sinus arrhythmia Voltage criteria for left ventricular hypertrophy Early repolarization</p><p><b>病人</b>：<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>檢驗日期</b>：2023-09-07</p></div>"
},
"status" : "final",
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{
"coding" : [
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"code" : "30954-2"
}
],
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}
],
"code" : {
"text" : "心電圖(EKG)"
},
"subject" : {
🔗 "reference" : "Patient/Patient-min"
},
"effectiveDateTime" : "2023-09-07",
"valueString" : "Normal sinus rhythmwith sinus arrhythmia Voltage criteria for left ventricular hypertrophy Early repolarization"
}
},
{
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"resource" : {
"resourceType" : "Observation",
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},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>檢驗／特殊檢查</b></h3><p><b>分類</b>：Relevant diagnostic tests/laboratory data Narrative <span style=\"background: LightGoldenRodYellow; margin：4px; border：1px solid khaki\">( <a href=\"http://loinc.org\">LOINC Codes</a>#30954-2)</span></p><p><b>檢驗狀態</b>：Final <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://hl7.org/fhir/observation-status\">ObservationStatus</a>#final)</span></p><p><b>檢驗</b>：血色素檢查 <span style=\"background: LightGoldenRodYellow; margin：4px; border：1px solid khaki\">( <a href=\"https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-service-payment-tw\">臺灣醫療服務給付項目</a>#08003C)</span></p><p><b>檢驗值</b>：15.9 g/dL</p><p><b>病人</b>：<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>檢驗日期</b>：2023-09-06</p></div>"
},
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"category" : [
{
"coding" : [
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}
],
"code" : {
"coding" : [
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}
]
},
"subject" : {
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},
"effectiveDateTime" : "2023-09-06",
"valueQuantity" : {
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}
}
},
{
"fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/ImagingStudy/ImagingStudy-min",
"resource" : {
"resourceType" : "ImagingStudy",
"id" : "ImagingStudy-min",
"meta" : {
"profile" : [
🔗 "https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/imagingstudy-imri"
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},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>醫療影像檢查</b></h3><p><b>醫療影像檢查狀態</b>：Available <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://hl7.org/fhir/imagingstudy-status\">ImagingStudyStatus</a>#available)</span></p><p><b>病人</b>：<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>就醫事件</b>：<a href=\"Encounter-Encounter-min.html\">Encounter/Encounter-min</a></p><p><b>醫療影像檢查開始時間</b>：2023-09-07 11:01:20-0300</p><p><b>醫療影像檢查解讀者</b>：<a href=\"Practitioner-Practitioner-min.html\">Practitioner/Practitioner-min</a> \"劉伊詩\"</p><p><b>醫療影像檢查敘述</b>：No significant ro entgenological abnormality is observed.</p></div>"
},
"status" : "available",
"subject" : {
🔗 "reference" : "Patient/Patient-min"
},
"encounter" : {
🔗 "reference" : "Encounter/Encounter-min"
},
"started" : "2023-09-07T11:01:20+03:00",
"interpreter" : [
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🔗 "reference" : "Practitioner/Practitioner-min"
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],
"description" : "No significant ro entgenological abnormality is observed."
}
},
{
"fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/Observation/ObservationPathologyReport-min",
"resource" : {
"resourceType" : "Observation",
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"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>病理報告</b></h3><p><b>分類</b>：Pathology report Cancer Narrative <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://loinc.org\">LOINC Codes</a>#22034-3)</span></p><p><b>病理報告狀態</b>：Final <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://hl7.org/fhir/observation-status\">ObservationStatus</a>#final)</span></p><p><b>病理報告項目</b>：Anus, hemorrhoidectomy, hemorrhoid.</p><p><b>病理報告結果</b>：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</p><p><b>病人</b>：<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>檢驗日期</b>：2023-09-08</p><p><b>病理報告負責者</b>：<a href=\"Practitioner-Practitioner-min.html\">Practitioner/Practitioner-min</a> \"劉伊詩\"</p></div>"
},
"status" : "final",
"category" : [
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"coding" : [
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"system" : "http://loinc.org",
"code" : "22034-3",
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}
],
"code" : {
"text" : "Anus, hemorrhoidectomy, hemorrhoid."
},
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},
"effectiveDateTime" : "2023-09-08",
"performer" : [
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🔗 "reference" : "Practitioner/Practitioner-min"
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"valueString" : "The specimen submitted consists of 2 pieces of anal tissue measuring 1.4 cm in greatest dimension.\r\n Al1 for section. Microscopically, the section shows a picture of hemorrhoid, composed of dilated,\r\n tortuous and congested veins in the stroma of the anal mucosa"
}
},
{
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"resource" : {
"resourceType" : "Procedure",
"id" : "Procedure-min",
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>處置/手術</b></h3><p><b>處置/手術狀態</b>：Completed <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://hl7.org/fhir/event-status\">EventStatus</a>#completed)</span></p><p><b>處置/手術種類</b>：Surgical operation note description Narrative <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://loinc.org\">LOINC</a>#8724-7)</span></p><p><b>處置/手術的識別碼</b>：開放性痔靜脈叢部分切除術 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-pcs-2021-tw\">臺灣2021年中文版ICD-10-PCS</a>#06BY0ZC)</span></p><p><b>病人</b>：<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>就醫事件</b>：<a href=\"Encounter-Encounter-min.html\">Encounter/Encounter-min</a></p><p><b>處置/手術日期</b>：2023-09-08 11:25:11-08:00</p></div>"
},
"status" : "completed",
"category" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8724-7",
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}
]
},
"code" : {
"coding" : [
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"code" : "06BY0ZC",
"display" : "開放性痔靜脈叢部分切除術"
}
],
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},
"subject" : {
🔗 "reference" : "Patient/Patient-min"
},
"encounter" : {
🔗 "reference" : "Encounter/Encounter-min"
},
"performedDateTime" : "2023-09-08T11:25:11+08:00"
}
},
{
"fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/Procedure/ProcedureHospitalCourse-min",
"resource" : {
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"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>住院治療經過</b></h3><p><b>住院治療經過狀態</b>：Completed <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://hl7.org/fhir/event-status\">EventStatus</a>#completed)</span></p><p><b>住院治療經過種類</b>：Hospital course Narrative <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://loinc.org\">LOINC</a>#8648-8)</span></p><p><b>住院治療經過代碼</b>：Hospital course Narrative <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://loinc.org\">LOINC</a>#8648-8)</span></p><p><b>病人</b>：<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>就醫事件</b>：<a href=\"Encounter-Encounter-min.html\">Encounter/Encounter-min</a></p><p><b>住院治療經過</b>：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.</p></div>"
},
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{
"text" : "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."
}
]
}
},
{
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},
"text" : {
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>合併症與併發症</b></h3><p><b>臨床狀態</b>：Resolved <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://terminology.hl7.org/CodeSystem/condition-clinical\">ConditionClinicalStatusCodes</a>#resolved)</span></p><p><b>病情、問題或診斷分類</b>：解決 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://loinc.org\">Condition Category Codes</a>#55109-3)</span></p><p><b>病人</b>：<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>就醫事件</b>：<a href=\"Encounter-Encounter-min.html\">Encounter/Encounter-min</a></p><p><b>合併症與併發症</b>：術中及術後併發症及肌肉骨骼系統疾患，他處未歸類者 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2021-tw\">臺灣2021年中文版ICD-10-CM</a>#M96)</span></p><p><b>合併症與併發症診斷日期</b>：2023-09-07 10:00:14-0800</p></div>"
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"system" : "http://terminology.hl7.org/CodeSystem/condition-clinical",
"code" : "resolved",
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"text" : "解決"
},
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{
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{
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"code" : "55109-3",
"display" : "Complications Document"
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"code" : "M96",
"display" : "術中及術後併發症及肌肉骨骼系統疾患，他處未歸類者"
}
],
"text" : "術中及術後併發症及肌肉骨骼系統疾患，他處未歸類者"
},
"subject" : {
🔗 "reference" : "Patient/Patient-min"
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🔗 "reference" : "Encounter/Encounter-min"
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"recordedDate" : "2023-09-07T10:00:14+08:00"
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},
{
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"resource" : {
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"meta" : {
"profile" : [
🔗 "https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/careplan-imri"
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},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>出院指示</b></h3><p><b>狀態</b>：Completed <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://hl7.org/fhir/request-status\">RequestStatus</a>#completed)</span></p><p><b>類別</b>：Proposal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://hl7.org/fhir/request-intent\">Care Plan Intent</a>#proposal)</span></p><p><b>病人</b>：<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>就醫事件</b>：<a href=\"Encounter-Encounter-min.html\">Encounter/Encounter-min</a></p><p><b>出院指示</b>：出院指示</p><p><b>出院指示藥物</b>：<a href=\"MedicationRequest-MedicationRequest-min.html\">MedicationRequest/MedicationRequest-min</a></p></div>"
},
"status" : "completed",
"intent" : "proposal",
"description" : "出院指示",
"subject" : {
🔗 "reference" : "Patient/Patient-min"
},
"encounter" : {
🔗 "reference" : "Encounter/Encounter-min"
},
"activity" : [
{
"reference" : {
🔗 "reference" : "MedicationRequest/MedicationRequest-min"
}
}
]
}
},
{
"fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/MedicationRequest/MedicationRequest-min",
"resource" : {
"resourceType" : "MedicationRequest",
"id" : "MedicationRequest-min",
"meta" : {
"profile" : [
🔗 "https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/medicationrequest-imri"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>藥品請求</b></h3><p><b>藥品請求的狀態</b>：Active <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://terminology.hl7.org/CodeSystem/medicationrequest-status-reason\">MedicationRequest Status Reason Codes</a>#active)</span></p><p><b>藥品請求的意圖</b>：Proposal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://hl7.org/fhir/CodeSystem/medicationrequest-intent\">medicationRequest Intent</a>#proposal)</span></p><p><b>開立的藥品</b>：ASPIRIN TABLETS 500MG \"S.Y.\" <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medication-nhi-tw\">臺灣健保用藥品項</a>#A003092100)</span></p><p><b>病人</b>：<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>就醫事件</b>：<a href=\"Encounter-Encounter-min.html\">Encounter/Encounter-min</a></p><p><b>提出藥品請求請求者</b>：<a href=\"Practitioner-Practitioner-min.html\">Practitioner/Practitioner-min</a>\"劉伊詩\"</p><p><b>給藥執行者</b>：<a href=\"Practitioner-Practitioner-min.html\">Practitioner/Practitioner-min</a>\"劉伊詩\"</p><p><b>開立處方的原因</b>：<a href=\"CarePlan-CarePlan-min.html\">CarePlan/CarePlan-min</a></p></div>"
},
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"intent" : "proposal",
"medicationCodeableConcept" : {
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{
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"code" : "A003092100",
"display" : "ASPIRIN TABLETS 500MG \"S.Y.\""
}
]
},
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🔗 "reference" : "Patient/Patient-min"
},
"encounter" : {
🔗 "reference" : "Encounter/Encounter-min"
},
"requester" : {
🔗 "reference" : "Practitioner/Practitioner-min"
},
"performer" : {
🔗 "reference" : "Practitioner/Practitioner-min"
},
"basedOn" : [
{
🔗 "reference" : "CarePlan/CarePlan-min"
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}