醫查實作指引
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: 手術紀錄範例 - XML Representation

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<Bundle xmlns="http://hl7.org/fhir">
  <id value="BundleOperationNote-min"/>
  <meta>
    <profile
             value="https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/bundle-operationnote-imri"/>
  </meta>
  <identifier>
    <system value="https://www.cgh.org.tw/"/>
    <value value="00300003202308271146000017"/>
  </identifier>
  <type value="document"/>
  <timestamp value="2024-05-12T14:30:00+01:00"/>
  <entry>
    <fullUrl
             value="https://hitstdio.ntunhs.edu.tw/imri/Composition/CompositionOperationNote-min"/>
    <resource>
      <Composition>
        <id value="CompositionOperationNote-min"/>
        <meta>
          <profile
                   value="https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/composition-operationnote-imri"/>
        </meta>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <status value="final"/>
        <type>
          <coding>
            <system value="http://loinc.org"/>
            <code value="11504-8"/>
            <display value="Surgical operation note"/>
          </coding>
        </type>
        <subject>🔗 
          <reference value="Patient/Patient-min"/>
        </subject>
        <date value="2024-05-12T14:30:00+08:00"/>
        <author>🔗 
          <reference value="Organization/OrganizationHosp-min"/>
        </author>
        <title value="手術紀錄"/>
        <section>
          <title value="病人資訊"/>
          <code>
            <coding>
              <system value="http://loinc.org"/>
              <code value="52460-3"/>
              <display value="Patient Information"/>
            </coding>
          </code>
          <section>
            <code>
              <coding>
                <system value="http://loinc.org"/>
                <code value="882-1"/>
                <display value="ABO and Rh group [Type] in Blood"/>
              </coding>
            </code>
            <entry>🔗 
              <reference value="Observation/ObservationBloodType-min"/>
            </entry>
          </section>
        </section>
        <section>
          <title value="手術資訊"/>
          <code>
            <coding>
              <system value="http://loinc.org"/>
              <code value="11504-8"/>
              <display value="Surgical operation note"/>
            </coding>
          </code>
          <entry>🔗 
            <reference value="Procedure/Procedure-pro"/>
          </entry>
          <section>
            <code>
              <coding>
                <system value="http://loinc.org"/>
                <code value="10218-6"/>
                <display
                         value="Surgical operation note postoperative diagnosis Narrative"/>
              </coding>
            </code>
            <entry>🔗 
              <reference value="Condition/Condition-postope"/>
            </entry>
          </section>
          <section>
            <code>
              <coding>
                <system value="http://loinc.org"/>
                <code value="59770-8"/>
                <display value="Procedure estimated blood loss Narrative"/>
              </coding>
            </code>
            <entry>🔗 
              <reference value="Observation/ObservationBloodLoss-min"/>
            </entry>
          </section>
          <section>
            <code>
              <coding>
                <system value="http://loinc.org"/>
                <code value="59774-0"/>
                <display value="Procedure anesthesia Narrative"/>
              </coding>
            </code>
            <entry>🔗 
              <reference value="Procedure/ProcedureAnesthesiaMode-min"/>
            </entry>
          </section>
        </section>
      </Composition>
    </resource>
  </entry>
  <entry>
    <fullUrl value="https://hitstdio.ntunhs.edu.tw/imri/Patient/Patient-min"/>
    <resource>
      <Patient>
        <id value="Patient-min"/>
        <meta>
          <profile
                   value="https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/patient-imri"/>
        </meta>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <identifier>
          <use value="official"/>
          <type>
            <coding>
              <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
              <code value="NNxxx">
                <extension
                           url="https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/identifier-suffix">
                  <extension url="suffix">
                    <valueString value="TWN"/>
                  </extension>
                  <extension url="valueSet">
                    <valueCanonical
                                    value="http://hl7.org/fhir/ValueSet/iso3166-1-3"/>
                  </extension>
                </extension>
              </code>
            </coding>
          </type>
          <system value="http://www.moi.gov.tw"/>
          <value value="A123456789"/>
        </identifier>
        <identifier>
          <use value="official"/>
          <type>
            <coding>
              <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
              <code value="MR"/>
            </coding>
          </type>
          <system value="https://www.cgh.org.tw"/>
          <value value="70892114"/>
        </identifier>
        <name>
          <use value="usual"/>
          <text value="安格斯"/>
        </name>
        <gender value="male"/>
        <birthDate value="2000-02-02"/>
      </Patient>
    </resource>
  </entry>
  <entry>
    <fullUrl
             value="https://hitstdio.ntunhs.edu.tw/imri/Organization/OrganizationHosp-min"/>
    <resource>
      <Organization>
        <id value="OrganizationHosp-min"/>
        <meta>
          <profile
                   value="https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/organization-hosp-imri"/>
        </meta>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <identifier>
          <use value="official"/>
          <type>
            <coding>
              <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
              <code value="PRN"/>
            </coding>
          </type>
          <system
                  value="https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/organization-identifier-tw"/>
          <value value="1101020018"/>
        </identifier>
        <type>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/organization-type"/>
            <code value="prov"/>
          </coding>
        </type>
        <name value="國泰醫療財團法人國泰綜合醫院"/>
      </Organization>
    </resource>
  </entry>
  <entry>
    <fullUrl
             value="https://hitstdio.ntunhs.edu.tw/imri/Practitioner/Practitioner-min"/>
    <resource>
      <Practitioner>
        <id value="Practitioner-min"/>
        <meta>
          <profile
                   value="https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/practitioner-imri"/>
        </meta>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <name>
          <use value="official"/>
          <text value="劉伊詩"/>
        </name>
      </Practitioner>
    </resource>
  </entry>
  <entry>
    <fullUrl
             value="https://hitstdio.ntunhs.edu.tw/imri/Practitioner/Practitioner-huang"/>
    <resource>
      <Practitioner>
        <id value="Practitioner-huang"/>
        <meta>
          <profile
                   value="https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/practitioner-imri"/>
        </meta>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <name>
          <use value="official"/>
          <text value="黃依昇"/>
        </name>
      </Practitioner>
    </resource>
  </entry>
  <entry>
    <fullUrl
             value="https://hitstdio.ntunhs.edu.tw/imri/PractitionerRole/PractitionerRole-min"/>
    <resource>
      <PractitionerRole>
        <id value="PractitionerRole-min"/>
        <meta>
          <profile
                   value="https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/practitionerrole-imri"/>
        </meta>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <practitioner>🔗 
          <reference value="Practitioner/Practitioner-min"/>
          <display value="劉伊詩"/>
        </practitioner>
        <code>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="304292004"/>
            <display value="Surgeon"/>
          </coding>
        </code>
      </PractitionerRole>
    </resource>
  </entry>
  <entry>
    <fullUrl
             value="https://hitstdio.ntunhs.edu.tw/imri/PractitionerRole/PractitionerRole-anesthesia"/>
    <resource>
      <PractitionerRole>
        <id value="PractitionerRole-anesthesia"/>
        <meta>
          <profile
                   value="https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/practitionerrole-imri"/>
        </meta>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <practitioner>🔗 
          <reference value="Practitioner/Practitioner-huang"/>
          <display value="黃依昇"/>
        </practitioner>
        <code>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="88189002"/>
            <display value="Anesthesiologist"/>
          </coding>
        </code>
      </PractitionerRole>
    </resource>
  </entry>
  <entry>
    <fullUrl
             value="https://hitstdio.ntunhs.edu.tw/imri/Observation/ObservationBloodType-min"/>
    <resource>
      <Observation>
        <id value="ObservationBloodType-min"/>
        <meta>
          <profile
                   value="https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/observationbloodtype-imri"/>
        </meta>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <status value="final"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="882-1"/>
            <display value="ABO and Rh group [Type] in Blood"/>
          </coding>
          <text value="ABO and Rh group [Type] in Blood"/>
        </code>
        <subject>🔗 
          <reference value="Patient/Patient-min"/>
        </subject>
        <effectiveDateTime value="2023-09-08T11:25:11+08:00"/>
        <valueCodeableConcept>
          <coding>
            <system value="http://loinc.org"/>
            <code value="LA21327-4"/>
            <display value="B Pos"/>
          </coding>
        </valueCodeableConcept>
      </Observation>
    </resource>
  </entry>
  <entry>
    <fullUrl
             value="https://hitstdio.ntunhs.edu.tw/imri/Procedure/Procedure-pro"/>
    <resource>
      <Procedure>
        <id value="Procedure-pro"/>
        <meta>
          <profile
                   value="https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/procedureoperation-imri"/>
        </meta>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <status value="completed"/>
        <category>
          <coding>
            <system value="http://loinc.org"/>
            <code value="8724-7"/>
            <display value="Surgical operation note description Narrative"/>
          </coding>
        </category>
        <code>
          <coding>
            <system
                    value="https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-service-payment-tw"/>
            <code value="75607C"/>
            <display value="鼠蹊疝氣修補術-無腸切除"/>
          </coding>
        </code>
        <subject>🔗 
          <reference value="Patient/Patient-min"/>
        </subject>
        <performedDateTime value="2023-10-20"/>
        <performer>
          <actor>🔗 
            <reference value="PractitionerRole/PractitionerRole-min"/>
            <display value="劉伊詩"/>
          </actor>
        </performer>
        <reasonReference>🔗 
          <reference value="Condition/Condition-preope"/>
        </reasonReference>
        <bodySite>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="4312008"/>
            <display value="Anterior midline of abdomen"/>
          </coding>
        </bodySite>
        <report>🔗 
          <reference value="DocumentReference/DocumentReference-min"/>
        </report>
        <note>
          <text
                value="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 :"/>
        </note>
        <note>
          <text
                value="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"/>
        </note>
        <usedCode>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="256641009"/>
            <display value="Ribbon gauze"/>
          </coding>
        </usedCode>
      </Procedure>
    </resource>
  </entry>
  <entry>
    <fullUrl
             value="https://hitstdio.ntunhs.edu.tw/imri/Condition/Condition-preope"/>
    <resource>
      <Condition>
        <id value="Condition-preope"/>
        <meta>
          <profile
                   value="https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Condition-twcore"/>
        </meta>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <clinicalStatus>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
            <code value="remission"/>
          </coding>
        </clinicalStatus>
        <category>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/condition-category"/>
            <code value="encounter-diagnosis"/>
          </coding>
        </category>
        <code>
          <coding>
            <system
                    value="https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2021-tw"/>
            <code value="K82.4"/>
          </coding>
          <text value="膽囊膽固醇沈著症"/>
        </code>
        <subject>🔗 
          <reference value="Patient/Patient-min"/>
        </subject>
      </Condition>
    </resource>
  </entry>
  <entry>
    <fullUrl
             value="https://hitstdio.ntunhs.edu.tw/imri/Condition/Condition-postope"/>
    <resource>
      <Condition>
        <id value="Condition-postope"/>
        <meta>
          <profile
                   value="https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Condition-twcore"/>
        </meta>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <clinicalStatus>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
            <code value="remission"/>
          </coding>
        </clinicalStatus>
        <category>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/condition-category"/>
            <code value="encounter-diagnosis"/>
          </coding>
        </category>
        <code>
          <coding>
            <system
                    value="https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2021-tw"/>
            <code value="K82.4"/>
            <display value="膽囊膽固醇沈著症"/>
          </coding>
          <text value="gallbladder cholesterolosis polyp"/>
        </code>
        <subject>🔗 
          <reference value="Patient/Patient-min"/>
        </subject>
      </Condition>
    </resource>
  </entry>
  <entry>
    <fullUrl
             value="https://hitstdio.ntunhs.edu.tw/imri/DocumentReference/DocumentReference-min"/>
    <resource>
      <DocumentReference>
        <id value="DocumentReference-min"/>
        <meta>
          <profile
                   value="https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/DocumentReference-twcore"/>
        </meta>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <status value="current"/>
        <subject>🔗 
          <reference value="Patient/Patient-min"/>
        </subject>
        <content>
          <attachment>
            <contentType value="image/png"/>
            <url
                 value="https://telegraph-image-55i.pages.dev/file/3830a304a2eb70419c80a.png"/>
            <title value="gallbladder polyp"/>
          </attachment>
        </content>
      </DocumentReference>
    </resource>
  </entry>
  <entry>
    <fullUrl
             value="https://hitstdio.ntunhs.edu.tw/imri/Observation/ObservationBloodLoss-min"/>
    <resource>
      <Observation>
        <id value="ObservationBloodLoss-min"/>
        <meta>
          <profile
                   value="https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/observationbloodloss-imri"/>
        </meta>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <partOf>🔗 
          <reference value="Procedure/Procedure-pro"/>
        </partOf>
        <status value="final"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="59770-8"/>
            <display value="Procedure estimated blood loss Narrative"/>
          </coding>
          <text value="Procedure estimated blood loss Narrative"/>
        </code>
        <subject>🔗 
          <reference value="Patient/Patient-min"/>
        </subject>
        <effectiveDateTime value="2023-09-08T11:25:11+08:00"/>
        <valueQuantity>
          <value value="1"/>
          <unit value="C.C."/>
        </valueQuantity>
      </Observation>
    </resource>
  </entry>
  <entry>
    <fullUrl
             value="https://hitstdio.ntunhs.edu.tw/imri/Procedure/ProcedureAnesthesiaMode-min"/>
    <resource>
      <Procedure>
        <id value="ProcedureAnesthesiaMode-min"/>
        <meta>
          <profile
                   value="https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/procedure-anesthesiamode-imri"/>
        </meta>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <partOf>🔗 
          <reference value="Procedure/Procedure-pro"/>
        </partOf>
        <status value="completed"/>
        <category>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="399097000"/>
          </coding>
        </category>
        <code>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="274507007"/>
            <display value="Operative general anesthesia"/>
          </coding>
          <text value="全身麻醉"/>
        </code>
        <subject>🔗 
          <reference value="Patient/Patient-min"/>
        </subject>
        <performedDateTime value="2023-09-08T11:25:11+08:00"/>
        <performer>
          <actor>🔗 
            <reference value="PractitionerRole/PractitionerRole-anesthesia"/>
            <display value="黃依昇"/>
          </actor>
        </performer>
      </Procedure>
    </resource>
  </entry>
</Bundle>