Additional Resources Included in Document

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

Resource Composition:

手術紀錄

狀態：Final (CompositionStatus#final)

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

病人：Patient/Patient-min "安格斯"

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"

手術紀錄小節內容：

section[PatientInformation].section[bloodtype]： Observation/ObservationBloodType-min

section[OperationNote]： Procedure/Procedure-pro
section[OperationNote].section[postoperativeDiagnosis]： Condition/Condition-postope
section[OperationNote].section[bloodLoss]： Observation/ObservationBloodLoss-min
section[OperationNote].section[anesthesiaMode]： Procedure/ProcedureAnesthesiaMode-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/Practitioner/Practitioner-huang

Resource Practitioner:

醫師基本資料

姓名（official）：黃依昇

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

Resource PractitionerRole:

醫師角色基本資料

健康照護服務提供者：Practitioner/Practitioner-min "劉伊詩"

角色：手術醫師(Surgeon) （ SNOMED CT#304292004）

Entry 7 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/PractitionerRole/PractitionerRole-anesthesia

Resource PractitionerRole:

醫師角色基本資料

健康照護服務提供者：Practitioner/Practitioner-huang "黃依昇"

角色：麻醉醫師(Anesthesiologist) （ SNOMED CT#88189002）

Entry 8 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Observation/ObservationBloodType-min

Resource Observation:

血型

狀態：Final

項目：ABO and Rh group [Type] in Blood ( LOINCCodes#882-1)

病人：Patient/Patient-min "安格斯"

血型：B Pos ( LOINCCodes#LA21327-4)

Entry 9 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Procedure/Procedure-pro

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：鼠蹊疝氣修補術-無腸切除 ( 臺灣健保署醫療服務給付項目#75607C)

病人：Patient/Patient-min "安格斯"

處置/手術日期：2023-10-20

手術醫師：PractitionerRole/PractitionerRole-min "劉伊詩"

手術前診斷：Condition/Condition-preope "膽囊膽固醇沈著症"

手術部位：Anterior midline of abdomen ( SNOMEDCTBodyStructures#4312008)

手術發現：
1. Indication: (Gall bladder polyp).
2. Gall bladder: Normal; gallbladder wall thickening: (-), 1 mm.
3. Gall stone (No), Sludge (No), Spillage (No), Cystic duct impaction (No).
4. Cystic duct closed with (Hem-o-lok).
5. Cystic artery closed with (Hem-o-lok).
6. Intraoperative bile spillage (Yes), Stone spillage (No).
7. Drainage left (No).
8. Wound closure: (Primary closure).
9. Previous abdominal surgery: (No).
10. Port site: (3 ports in single incision).
11. Way of cholecystectomy: (Calot's triangle first).
12. Estimated blood loss: (1 ml).
13. Other intra-operation findings: (not specified)

手術過程紀錄：
1. Under general anesthesia, patient was put in supine position
2. Sterilized and draped the abdomen as usual
3. 2.5cm incision wound created at umbilicus, glove port was set, 3 ports were inserted via glove port
4. Approach Calot's triangle, dissect the serosa
5. Dissect cystic duct and cystic artery, present critical view of safety
6. Closed cystic artery with Hem-o-lok
7. Dissect gallbladder from gallbladder fossa
8. Closed cystic duct with Hem-o-lok
9. After hemostasis, retract specimen with endo-bag, close the wound in layers

手術圖像：DocumentReference/DocumentReference-min "gallbladder polyp"

手術特材：Ribbon gauze ( FHIRDeviceTypes#256641009)

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

Resource Condition:

病情、問題或診斷資料

臨床狀態：Remission ( ConditionClinicalStatusCodes#remission)

病情、問題或診斷分類：Encounter Diagnosis ( Condition Category Codes#encounter-diagnosis)

病人：Patient/Patient-min "安格斯"

病情、問題或診斷識別：膽囊膽固醇沈著症 ( 臺灣2021年中文版ICD-10-CM#K82.4)

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

Resource Condition:

病情、問題或診斷資料

臨床狀態：Remission ( ConditionClinicalStatusCodes#remission)

病情、問題或診斷分類：Encounter Diagnosis ( Condition Category Codes#encounter-diagnosis)

病人：Patient/Patient-min "安格斯"

病情、問題或診斷識別：gallbladder cholesterolosis polyp ( 臺灣2021年中文版ICD-10-CM#K82.4)

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

Resource DocumentReference:

手術圖像

狀態：Current ( DocumentReferenceStatus#current)

病人：Patient/Patient-min "安格斯"

紀錄中使用的檔案：

檔案類型(type)：image/png

檔案： gallbladder polyp

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

Resource Observation:

失血量

手術：Procedure/Procedure-pro

狀態：Final

項目：Procedure estimated blood loss Narrative ( LOINCCodes#59770-8)

病人：Patient/Patient-min "安格斯"

失血量：1 C.C.

Entry 14 - fullUrl = https://hitstdio.ntunhs.edu.tw/imri/Procedure/ProcedureAnesthesiaMode-min

Resource Procedure:

麻醉模式

手術：Procedure/Procedure-pro

麻醉模式狀態：Completed ( EventStatus#completed)

處置/手術種類：Administration of anesthesia ( ProcedureCategoryCodes(SNOMEDCT)#399097000)

麻醉模式：全身麻醉 (Operative general anesthesia) ( SCTAnesthesia#274507007)

病人：Patient/Patient-min "安格斯"

麻醉日期：2023-09-08 11:25:11-08:00

麻醉醫師：PractitionerRole/PractitionerRole-anesthesia "黃依昇"