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" : [
{
🔗 "reference" : "Organization/OrganizationHosp-min"
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{
🔗 "reference" : "Practitioner/Practitioner-min"
}
],
"title" : "出院病歷摘要",
"section" : [
{
"title" : "住院臆斷",
"code" : {
"coding" : [
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"system" : "http://loinc.org",
"code" : "46241-6",
"display" : "Hospital admission diagnosis Narrative - Reported"
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"entry" : [
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"title" : "出院診斷",
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"system" : "http://loinc.org",
"code" : "11535-2",
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"entry" : [
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{
"title" : "癌症期別",
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"system" : "http://loinc.org",
"code" : "22037-6",
"display" : "Staging Cancer Narrative"
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"entry" : [
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🔗 "reference" : "Observation/ObservationCancerStaging-min"
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{
"title" : "主訴",
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"code" : "10154-3",
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"entry" : [
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🔗 "reference" : "Condition/ConditionChiefComplaint-min"
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{
"title" : "病史",
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"code" : "10164-2",
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🔗 "reference" : "Condition/ConditionPresentIllness-min"
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{
"title" : "理學檢查發現",
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"entry" : [
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🔗 "reference" : "Observation/ObservationPhysicalExamination-min"
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{
"title" : "檢驗與特殊檢查",
"code" : {
"coding" : [
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"system" : "http://loinc.org",
"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",
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"code" : "18748-4",
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{
"title" : "病理報告",
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"code" : "22034-3",
"display" : "Pathology report Cancer Narrative"
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"entry" : [
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🔗 "reference" : "Observation/ObservationPathologyReport-min"
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},
{
"title" : "手術日期及方法",
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"code" : "8724-7",
"display" : "Surgical operation note description Narrative"
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{
"title" : "住院治療經過",
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{
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{
"title" : "合併症與併發症",
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"code" : "55109-3",
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{
"title" : "出院指示",
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"code" : "8653-8",
"display" : "Hospital Discharge instructions"
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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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