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

: 手術紀錄範例 - JSON Representation

Raw json | Download


{
  "resourceType" : "Bundle",
  "id" : "BundleOperationNote-min",
  "meta" : {
    "profile" : [
      🔗 "https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/bundle-operationnote-imri"
    ]
  },
  "identifier" : {
    "system" : "https://www.cgh.org.tw/",
    "value" : "00300003202308271146000017"
  },
  "type" : "document",
  "timestamp" : "2024-05-12T14:30:00+01:00",
  "entry" : [
    {
      "fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/Composition/CompositionOperationNote-min",
      "resource" : {
        "resourceType" : "Composition",
        "id" : "CompositionOperationNote-min",
        "meta" : {
          "profile" : [
            🔗 "https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/composition-operationnote-imri"
          ]
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>手術紀錄</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>:Surgical operation note <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"https://loinc.org/\">LOINC</a>#11504-8)</span></p><p><b>病人</b>:<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</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>手術紀錄小節內容:</b></p><blockquote><p><b>section[PatientInformation].section[bloodtype]</b>: <a href=\"Observation-ObservationBloodType-min.html\">Observation/ObservationBloodType-min</a></p><p><b>section[OperationNote]</b>: <a href=\"Procedure-Procedure-pro.html\">Procedure/Procedure-pro</a><br/><b>section[OperationNote].section[postoperativeDiagnosis]</b>: <a href=\"Condition-Condition-postope.html\">Condition/Condition-postope</a><br/><b>section[OperationNote].section[bloodLoss]</b>: <a href=\"Observation-ObservationBloodLoss-min.html\">Observation/ObservationBloodLoss-min</a><br/><b>section[OperationNote].section[anesthesiaMode]</b>: <a href=\"Procedure-ProcedureAnesthesiaMode-min.html\">Procedure/ProcedureAnesthesiaMode-min</a></p></blockquote></div>"
        },
        "status" : "final",
        "type" : {
          "coding" : [
            {
              "system" : "http://loinc.org",
              "code" : "11504-8",
              "display" : "Surgical operation note"
            }
          ]
        },
        "subject" : {
          🔗 "reference" : "Patient/Patient-min"
        },
        "date" : "2024-05-12T14:30:00+08:00",
        "author" : [
          {
            🔗 "reference" : "Organization/OrganizationHosp-min"
          }
        ],
        "title" : "手術紀錄",
        "section" : [
          {
            "title" : "病人資訊",
            "code" : {
              "coding" : [
                {
                  "system" : "http://loinc.org",
                  "code" : "52460-3",
                  "display" : "Patient Information"
                }
              ]
            },
            "section" : [
              {
                "code" : {
                  "coding" : [
                    {
                      "system" : "http://loinc.org",
                      "code" : "882-1",
                      "display" : "ABO and Rh group [Type] in Blood"
                    }
                  ]
                },
                "entry" : [
                  {
                    🔗 "reference" : "Observation/ObservationBloodType-min"
                  }
                ]
              }
            ]
          },
          {
            "title" : "手術資訊",
            "code" : {
              "coding" : [
                {
                  "system" : "http://loinc.org",
                  "code" : "11504-8",
                  "display" : "Surgical operation note"
                }
              ]
            },
            "entry" : [
              {
                🔗 "reference" : "Procedure/Procedure-pro"
              }
            ],
            "section" : [
              {
                "code" : {
                  "coding" : [
                    {
                      "system" : "http://loinc.org",
                      "code" : "10218-6",
                      "display" : "Surgical operation note postoperative diagnosis Narrative"
                    }
                  ]
                },
                "entry" : [
                  {
                    🔗 "reference" : "Condition/Condition-postope"
                  }
                ]
              },
              {
                "code" : {
                  "coding" : [
                    {
                      "system" : "http://loinc.org",
                      "code" : "59770-8",
                      "display" : "Procedure estimated blood loss Narrative"
                    }
                  ]
                },
                "entry" : [
                  {
                    🔗 "reference" : "Observation/ObservationBloodLoss-min"
                  }
                ]
              },
              {
                "code" : {
                  "coding" : [
                    {
                      "system" : "http://loinc.org",
                      "code" : "59774-0",
                      "display" : "Procedure anesthesia Narrative"
                    }
                  ]
                },
                "entry" : [
                  {
                    🔗 "reference" : "Procedure/ProcedureAnesthesiaMode-min"
                  }
                ]
              }
            ]
          }
        ]
      }
    },
    {
      "fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/Patient/Patient-min",
      "resource" : {
        "resourceType" : "Patient",
        "id" : "Patient-min",
        "meta" : {
          "profile" : [
            🔗 "https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/patient-imri"
          ]
        },
        "text" : {
          "status" : "generated",
          "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>"
        },
        "identifier" : [
          {
            "use" : "official",
            "type" : {
              "coding" : [
                {
                  "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
                  "code" : "NNxxx",
                  "_code" : {
                    "extension" : [
                      {
                        "extension" : [
                          {
                            "url" : "suffix",
                            "valueString" : "TWN"
                          },
                          {
                            "url" : "valueSet",
                            "valueCanonical" : "http://hl7.org/fhir/ValueSet/iso3166-1-3"
                          }
                        ],
                        "url" : "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/identifier-suffix"
                      }
                    ]
                  }
                }
              ]
            },
            "system" : "http://www.moi.gov.tw",
            "value" : "A123456789"
          },
          {
            "use" : "official",
            "type" : {
              "coding" : [
                {
                  "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
                  "code" : "MR"
                }
              ]
            },
            "system" : "https://www.cgh.org.tw",
            "value" : "70892114"
          }
        ],
        "name" : [
          {
            "use" : "usual",
            "text" : "安格斯"
          }
        ],
        "gender" : "male",
        "birthDate" : "2000-02-02"
      }
    },
    {
      "fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/Organization/OrganizationHosp-min",
      "resource" : {
        "resourceType" : "Organization",
        "id" : "OrganizationHosp-min",
        "meta" : {
          "profile" : [
            🔗 "https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/organization-hosp-imri"
          ]
        },
        "text" : {
          "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"
                }
              ]
            },
            "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"
      }
    },
    {
      "fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/Practitioner/Practitioner-min",
      "resource" : {
        "resourceType" : "Practitioner",
        "id" : "Practitioner-min",
        "meta" : {
          "profile" : [
            🔗 "https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/practitioner-imri"
          ]
        },
        "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/Practitioner/Practitioner-huang",
      "resource" : {
        "resourceType" : "Practitioner",
        "id" : "Practitioner-huang",
        "meta" : {
          "profile" : [
            🔗 "https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/practitioner-imri"
          ]
        },
        "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>:黃依昇</p></div>"
        },
        "name" : [
          {
            "use" : "official",
            "text" : "黃依昇"
          }
        ]
      }
    },
    {
      "fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/PractitionerRole/PractitionerRole-min",
      "resource" : {
        "resourceType" : "PractitionerRole",
        "id" : "PractitionerRole-min",
        "meta" : {
          "profile" : [
            🔗 "https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/practitionerrole-imri"
          ]
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>醫師角色基本資料</b></h3><p><b>健康照護服務提供者</b>:<a href=\"Practitioner-Practitioner-min.html\">Practitioner/Practitioner-min</a> \"劉伊詩\"</p><p><b>角色</b>:手術醫師(Surgeon) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://snomed.info/sct\">SNOMED CT</a>#304292004)</span></p></div>"
        },
        "practitioner" : {
          🔗 "reference" : "Practitioner/Practitioner-min",
          "display" : "劉伊詩"
        },
        "code" : [
          {
            "coding" : [
              {
                "system" : "http://snomed.info/sct",
                "code" : "304292004",
                "display" : "Surgeon"
              }
            ]
          }
        ]
      }
    },
    {
      "fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/PractitionerRole/PractitionerRole-anesthesia",
      "resource" : {
        "resourceType" : "PractitionerRole",
        "id" : "PractitionerRole-anesthesia",
        "meta" : {
          "profile" : [
            🔗 "https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/practitionerrole-imri"
          ]
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>醫師角色基本資料</b></h3><p><b>健康照護服務提供者</b>:<a href=\"Practitioner-Practitioner-huang.html\">Practitioner/Practitioner-huang</a> \"黃依昇\"</p><p><b>角色</b>:麻醉醫師(Anesthesiologist) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://snomed.info/sct\">SNOMED CT</a>#88189002)</span></p></div>"
        },
        "practitioner" : {
          🔗 "reference" : "Practitioner/Practitioner-huang",
          "display" : "黃依昇"
        },
        "code" : [
          {
            "coding" : [
              {
                "system" : "http://snomed.info/sct",
                "code" : "88189002",
                "display" : "Anesthesiologist"
              }
            ]
          }
        ]
      }
    },
    {
      "fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/Observation/ObservationBloodType-min",
      "resource" : {
        "resourceType" : "Observation",
        "id" : "ObservationBloodType-min",
        "meta" : {
          "profile" : [
            🔗 "https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/observationbloodtype-imri"
          ]
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>血型</b></h3><p><b>狀態</b>:Final</p><p><b>項目</b>:ABO and Rh group [Type] in Blood <span style=\"background: LightGoldenRodYellow; margin:4px; border:1px solid khaki\">( <a href=\"http://loinc.org\">LOINCCodes</a>#882-1)</span></p><p><b>病人</b>:<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>血型</b>:B Pos <span style=\"background: LightGoldenRodYellow; margin:4px; border:1px solid khaki\">( <a href=\"http://loinc.org\">LOINCCodes</a>#LA21327-4)</span></p></div>"
        },
        "status" : "final",
        "code" : {
          "coding" : [
            {
              "system" : "http://loinc.org",
              "code" : "882-1",
              "display" : "ABO and Rh group [Type] in Blood"
            }
          ],
          "text" : "ABO and Rh group [Type] in Blood"
        },
        "subject" : {
          🔗 "reference" : "Patient/Patient-min"
        },
        "effectiveDateTime" : "2023-09-08T11:25:11+08:00",
        "valueCodeableConcept" : {
          "coding" : [
            {
              "system" : "http://loinc.org",
              "code" : "LA21327-4",
              "display" : "B Pos"
            }
          ]
        }
      }
    },
    {
      "fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/Procedure/Procedure-pro",
      "resource" : {
        "resourceType" : "Procedure",
        "id" : "Procedure-pro",
        "meta" : {
          "profile" : [
            🔗 "https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/procedureoperation-imri"
          ]
        },
        "text" : {
          "status" : "generated",
          "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>:鼠蹊疝氣修補術-無腸切除 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-service-payment-tw\">臺灣健保署醫療服務給付項目</a>#75607C)</span></p><p><b>病人</b>:<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>處置/手術日期</b>:2023-10-20</p><p><b>手術醫師</b>:<a href=\"PractitionerRole-PractitionerRole-min.html\">PractitionerRole/PractitionerRole-min</a> \"劉伊詩\"</p><p><b>手術前診斷</b>:<a href=\"Condition-Condition-preope.html\">Condition/Condition-preope</a> \"膽囊膽固醇沈著症\"</p><p><b>手術部位</b>:Anterior midline of abdomen <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://snomed.info/sct\">SNOMEDCTBodyStructures</a>#4312008)</span></p><p><b>手術發現</b>:<br/>1. Indication: (Gall bladder polyp).<br/>2. Gall bladder: Normal; gallbladder wall thickening: (-), 1 mm.<br/>3. Gall stone (No), Sludge (No), Spillage (No), Cystic duct impaction (No).<br/>4. Cystic duct closed with (Hem-o-lok).<br/>5. Cystic artery closed with (Hem-o-lok).<br/>6. Intraoperative bile spillage (Yes), Stone spillage (No).<br/>7. Drainage left (No).<br/>8. Wound closure: (Primary closure).<br/>9. Previous abdominal surgery: (No).<br/>10. Port site: (3 ports in single incision).<br/>11. Way of cholecystectomy: (Calot's triangle first).<br/>12. Estimated blood loss: (1 ml).<br/>13. Other intra-operation findings: (not specified)</p><p><b>手術過程紀錄</b>:<br/>1. Under general anesthesia, patient was put in supine position<br/>2. Sterilized and draped the abdomen as usual<br/>3. 2.5cm incision wound created at umbilicus, glove port was set, 3 ports were inserted via glove port<br/>4. Approach Calot's triangle, dissect the serosa<br/>5. Dissect cystic duct and cystic artery, present critical view of safety<br/>6. Closed cystic artery with Hem-o-lok<br/>7. Dissect gallbladder from gallbladder fossa<br/>8. Closed cystic duct with Hem-o-lok<br/>9. After hemostasis, retract specimen with endo-bag, close the wound in layers</p><p><b>手術圖像</b>:<a href=\"DocumentReference-DocumentReference-min.html\">DocumentReference/DocumentReference-min</a> \"<a href=\"https://telegraph-image-55i.pages.dev/file/3830a304a2eb70419c80a.png\">gallbladder polyp</a>\"</p><p><b>手術特材</b>:Ribbon gauze <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://snomed.info/sct\">FHIRDeviceTypes</a>#256641009)</span></p></div>"
        },
        "status" : "completed",
        "category" : {
          "coding" : [
            {
              "system" : "http://loinc.org",
              "code" : "8724-7",
              "display" : "Surgical operation note description Narrative"
            }
          ]
        },
        "code" : {
          "coding" : [
            {
              "system" : "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-service-payment-tw",
              "code" : "75607C",
              "display" : "鼠蹊疝氣修補術-無腸切除"
            }
          ]
        },
        "subject" : {
          🔗 "reference" : "Patient/Patient-min"
        },
        "performedDateTime" : "2023-10-20",
        "performer" : [
          {
            "actor" : {
              🔗 "reference" : "PractitionerRole/PractitionerRole-min",
              "display" : "劉伊詩"
            }
          }
        ],
        "reasonReference" : [
          {
            🔗 "reference" : "Condition/Condition-preope"
          }
        ],
        "bodySite" : [
          {
            "coding" : [
              {
                "system" : "http://snomed.info/sct",
                "code" : "4312008",
                "display" : "Anterior midline of abdomen"
              }
            ]
          }
        ],
        "report" : [
          {
            🔗 "reference" : "DocumentReference/DocumentReference-min"
          }
        ],
        "note" : [
          {
            "text" : "1. indication: (gall bladder polyp) 2. gall bladder: normal; gallbladder wall thickening: (-), _1_mm 3.gall stone (no), sludge (no), spiliage (no), cystic duct impaction(no) 4. cystic duct closed with (hemolock) 5. cystic artery closed with (hemolock) 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 operation findings :"
          },
          {
            "text" : "1. Under general anesthesia, patient was put in supine position 2. Sterlized 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 trangle, dissect the serosa 5. dissect cystic duct and cystic artery, present critical view of safty 6. closed cystic artery with hemolock 7. dissect gallbladder from gallbladder fossa 8. closed cystic duct with hemolock 9. After hemostasis, retract specimen with endo-bag, close the wound in layers"
          }
        ],
        "usedCode" : [
          {
            "coding" : [
              {
                "system" : "http://snomed.info/sct",
                "code" : "256641009",
                "display" : "Ribbon gauze"
              }
            ]
          }
        ]
      }
    },
    {
      "fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/Condition/Condition-preope",
      "resource" : {
        "resourceType" : "Condition",
        "id" : "Condition-preope",
        "meta" : {
          "profile" : [
            🔗 "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Condition-twcore"
          ]
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>病情、問題或診斷資料</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>:Encounter Diagnosis <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://terminology.hl7.org/CodeSystem/condition-category\">Condition Category Codes</a>#encounter-diagnosis)</span></p><p><b>病人</b>:<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>病情、問題或診斷識別</b>:膽囊膽固醇沈著症 <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>#K82.4)</span></p></div>"
        },
        "clinicalStatus" : {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical",
              "code" : "remission"
            }
          ]
        },
        "category" : [
          {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/condition-category",
                "code" : "encounter-diagnosis"
              }
            ]
          }
        ],
        "code" : {
          "coding" : [
            {
              "system" : "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2021-tw",
              "code" : "K82.4"
            }
          ],
          "text" : "膽囊膽固醇沈著症"
        },
        "subject" : {
          🔗 "reference" : "Patient/Patient-min"
        }
      }
    },
    {
      "fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/Condition/Condition-postope",
      "resource" : {
        "resourceType" : "Condition",
        "id" : "Condition-postope",
        "meta" : {
          "profile" : [
            🔗 "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Condition-twcore"
          ]
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>病情、問題或診斷資料</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>:Encounter Diagnosis <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://terminology.hl7.org/CodeSystem/condition-category\">Condition Category Codes</a>#encounter-diagnosis)</span></p><p><b>病人</b>:<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>病情、問題或診斷識別</b>:gallbladder cholesterolosis polyp <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>#K82.4)</span></p></div>"
        },
        "clinicalStatus" : {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical",
              "code" : "remission"
            }
          ]
        },
        "category" : [
          {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/condition-category",
                "code" : "encounter-diagnosis"
              }
            ]
          }
        ],
        "code" : {
          "coding" : [
            {
              "system" : "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2021-tw",
              "code" : "K82.4",
              "display" : "膽囊膽固醇沈著症"
            }
          ],
          "text" : "gallbladder cholesterolosis polyp"
        },
        "subject" : {
          🔗 "reference" : "Patient/Patient-min"
        }
      }
    },
    {
      "fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/DocumentReference/DocumentReference-min",
      "resource" : {
        "resourceType" : "DocumentReference",
        "id" : "DocumentReference-min",
        "meta" : {
          "profile" : [
            🔗 "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/DocumentReference-twcore"
          ]
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>手術圖像</b></h3><p><b>狀態</b>:Current <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://hl7.org/fhir/R4/codesystem-document-reference-status.html\">DocumentReferenceStatus</a>#current)</span></p><p><b>病人</b>:<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>紀錄中使用的檔案</b>:</p><blockquote><p><b>檔案類型(type)</b>:image/png</p><br/><p><b>檔案</b>:<a href=\"https://telegraph-image-55i.pages.dev/file/3830a304a2eb70419c80a.png\"> gallbladder polyp</a></p></blockquote></div>"
        },
        "status" : "current",
        "subject" : {
          🔗 "reference" : "Patient/Patient-min"
        },
        "content" : [
          {
            "attachment" : {
              "contentType" : "image/png",
              "url" : "https://telegraph-image-55i.pages.dev/file/3830a304a2eb70419c80a.png",
              "title" : "gallbladder polyp"
            }
          }
        ]
      }
    },
    {
      "fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/Observation/ObservationBloodLoss-min",
      "resource" : {
        "resourceType" : "Observation",
        "id" : "ObservationBloodLoss-min",
        "meta" : {
          "profile" : [
            🔗 "https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/observationbloodloss-imri"
          ]
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>失血量</b></h3><p><b>手術</b>:<a href=\"Procedure-Procedure-pro.html\">Procedure/Procedure-pro</a></p><p><b>狀態</b>:Final</p><p><b>項目</b>:Procedure estimated blood loss Narrative <span style=\"background: LightGoldenRodYellow; margin:4px; border:1px solid khaki\">( <a href=\"http://loinc.org\">LOINCCodes</a>#59770-8)</span></p><p><b>病人</b>:<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>失血量</b>:1 C.C.</p></div>"
        },
        "partOf" : [
          {
            🔗 "reference" : "Procedure/Procedure-pro"
          }
        ],
        "status" : "final",
        "code" : {
          "coding" : [
            {
              "system" : "http://loinc.org",
              "code" : "59770-8",
              "display" : "Procedure estimated blood loss Narrative"
            }
          ],
          "text" : "Procedure estimated blood loss Narrative"
        },
        "subject" : {
          🔗 "reference" : "Patient/Patient-min"
        },
        "effectiveDateTime" : "2023-09-08T11:25:11+08:00",
        "valueQuantity" : {
          "value" : 1,
          "unit" : "C.C."
        }
      }
    },
    {
      "fullUrl" : "https://hitstdio.ntunhs.edu.tw/imri/Procedure/ProcedureAnesthesiaMode-min",
      "resource" : {
        "resourceType" : "Procedure",
        "id" : "ProcedureAnesthesiaMode-min",
        "meta" : {
          "profile" : [
            🔗 "https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/procedure-anesthesiamode-imri"
          ]
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>麻醉模式</b></h3><p><b>手術</b>:<a href=\"Procedure-Procedure-pro.html\">Procedure/Procedure-pro</a></p><p><b>麻醉模式狀態</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>:Administration of anesthesia <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://snomed.info/sct\">ProcedureCategoryCodes(SNOMEDCT)</a>#399097000)</span></p><p><b>麻醉模式</b>:全身麻醉 (Operative general anesthesia) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://snomed.info/sct\">SCTAnesthesia</a>#274507007)</span></p><p><b>病人</b>:<a href=\"Patient-Patient-min.html\">Patient/Patient-min</a> \"安格斯\"</p><p><b>麻醉日期</b>:2023-09-08 11:25:11-08:00</p><p><b>麻醉醫師</b>:<a href=\"PractitionerRole-PractitionerRole-anesthesia.html\">PractitionerRole/PractitionerRole-anesthesia</a> \"黃依昇\"</p></div>"
        },
        "partOf" : [
          {
            🔗 "reference" : "Procedure/Procedure-pro"
          }
        ],
        "status" : "completed",
        "category" : {
          "coding" : [
            {
              "system" : "http://snomed.info/sct",
              "code" : "399097000"
            }
          ]
        },
        "code" : {
          "coding" : [
            {
              "system" : "http://snomed.info/sct",
              "code" : "274507007",
              "display" : "Operative general anesthesia"
            }
          ],
          "text" : "全身麻醉"
        },
        "subject" : {
          🔗 "reference" : "Patient/Patient-min"
        },
        "performedDateTime" : "2023-09-08T11:25:11+08:00",
        "performer" : [
          {
            "actor" : {
              🔗 "reference" : "PractitionerRole/PractitionerRole-anesthesia",
              "display" : "黃依昇"
            }
          }
        ]
      }
    }
  ]
}