醫查實作指引
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: 出院病歷摘要 - TTL Representation

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <https://loinc.org/rdf/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:Composition ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "CompositionDischargeSummary-min"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/composition-dischargesummary-imri"^^xsd:anyURI ;
fhir:link <https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/composition-dischargesummary-imri>     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir: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>"
  ] ; # 
  fhir:status [ fhir:v "final"] ; # 
  fhir:type [
    ( fhir:coding [
a loinc:18842-5 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "18842-5" ] ;
fhir:display [ fhir:v "Discharge summary" ]     ] )
  ] ; # 
  fhir:subject [
fhir:reference [ fhir:v "Patient/Patient-min" ]
  ] ; # 
  fhir:encounter [
fhir:reference [ fhir:v "Encounter/Encounter-min" ]
  ] ; # 
  fhir:date [ fhir:v "2024-05-12T14:30:00+08:00"^^xsd:dateTime] ; # 
  fhir:author ( [
fhir:reference [ fhir:v "Organization/OrganizationHosp-min" ]
  ] [
fhir:reference [ fhir:v "Practitioner/Practitioner-min" ]
  ] ) ; # 
  fhir:title [ fhir:v "出院病歷摘要"] ; # 
  fhir:section ( [
fhir:title [ fhir:v "住院臆斷" ] ;
fhir:code [
      ( fhir:coding [
a loinc:46241-6 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "46241-6" ] ;
fhir:display [ fhir:v "Hospital admission diagnosis Narrative - Reported" ]       ] )     ] ;
    ( fhir:entry [
fhir:reference [ fhir:v "Observation/ObservationImpression-min" ]     ] )
  ] [
fhir:title [ fhir:v "出院診斷" ] ;
fhir:code [
      ( fhir:coding [
a loinc:11535-2 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "11535-2" ] ;
fhir:display [ fhir:v "Hospital discharge Dx Narrative" ]       ] )     ] ;
    ( fhir:entry [
fhir:reference [ fhir:v "Condition/ConditionDischargeDiagnosis-min" ]     ] )
  ] [
fhir:title [ fhir:v "癌症期別" ] ;
fhir:code [
      ( fhir:coding [
a loinc:22037-6 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "22037-6" ] ;
fhir:display [ fhir:v "Staging Cancer Narrative" ]       ] )     ] ;
    ( fhir:entry [
fhir:reference [ fhir:v "Observation/ObservationCancerStaging-min" ]     ] )
  ] [
fhir:title [ fhir:v "主訴" ] ;
fhir:code [
      ( fhir:coding [
a loinc:10154-3 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "10154-3" ] ;
fhir:display [ fhir:v "Chief complaint Narrative - Reported" ]       ] )     ] ;
    ( fhir:entry [
fhir:reference [ fhir:v "Condition/ConditionChiefComplaint-min" ]     ] )
  ] [
fhir:title [ fhir:v "病史" ] ;
fhir:code [
      ( fhir:coding [
a loinc:10164-2 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "10164-2" ] ;
fhir:display [ fhir:v "History of Present illness Narrative" ]       ] )     ] ;
    ( fhir:entry [
fhir:reference [ fhir:v "Condition/ConditionPresentIllness-min" ]     ] )
  ] [
fhir:title [ fhir:v "理學檢查發現" ] ;
fhir:code [
      ( fhir:coding [
a loinc:29545-1 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "29545-1" ] ;
fhir:display [ fhir:v "Physical findings Narrative" ]       ] )     ] ;
    ( fhir:entry [
fhir:reference [ fhir:v "Observation/ObservationPhysicalExamination-min" ]     ] )
  ] [
fhir:title [ fhir:v "檢驗與特殊檢查" ] ;
fhir:code [
      ( fhir:coding [
a loinc:30954-2 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "30954-2" ] ;
fhir:display [ fhir:v "Relevant diagnostic tests/laboratory data Narrative" ]       ] )     ] ;
    ( fhir:entry [
fhir:reference [ fhir:v "Observation/ObservationLaboratory-min" ]     ] [
fhir:reference [ fhir:v "Observation/ObservationLaboratory-lab" ]     ] )
  ] [
fhir:title [ fhir:v "醫療影像檢查" ] ;
fhir:code [
      ( fhir:coding [
a loinc:18748-4 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "18748-4" ] ;
fhir:display [ fhir:v "Diagnostic imaging study" ]       ] )     ] ;
    ( fhir:entry [
fhir:reference [ fhir:v "ImagingStudy/ImagingStudy-min" ]     ] )
  ] [
fhir:title [ fhir:v "病理報告" ] ;
fhir:code [
      ( fhir:coding [
a loinc:22034-3 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "22034-3" ] ;
fhir:display [ fhir:v "Pathology report Cancer Narrative" ]       ] )     ] ;
    ( fhir:entry [
fhir:reference [ fhir:v "Observation/ObservationPathologyReport-min" ]     ] )
  ] [
fhir:title [ fhir:v "手術日期及方法" ] ;
fhir:code [
      ( fhir:coding [
a loinc:8724-7 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "8724-7" ] ;
fhir:display [ fhir:v "Surgical operation note description Narrative" ]       ] )     ] ;
    ( fhir:entry [
fhir:reference [ fhir:v "Procedure/Procedure-min" ]     ] )
  ] [
fhir:title [ fhir:v "住院治療經過" ] ;
fhir:code [
      ( fhir:coding [
a loinc:8648-8 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "8648-8" ] ;
fhir:display [ fhir:v "Hospital course Narrative" ]       ] )     ] ;
    ( fhir:entry [
fhir:reference [ fhir:v "Procedure/ProcedureHospitalCourse-min" ]     ] [
fhir:reference [ fhir:v "Location/Location-min" ]     ] )
  ] [
fhir:title [ fhir:v "合併症與併發症" ] ;
fhir:code [
      ( fhir:coding [
a loinc:55109-3 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "55109-3" ] ;
fhir:display [ fhir:v "Complications Document" ]       ] )     ] ;
    ( fhir:entry [
fhir:reference [ fhir:v "Condition/ConditionComorbiditiesandComplications-min" ]     ] )
  ] [
fhir:title [ fhir:v "出院指示" ] ;
fhir:code [
      ( fhir:coding [
a loinc:8653-8 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "8653-8" ] ;
fhir:display [ fhir:v "Hospital Discharge instructions" ]       ] )     ] ;
    ( fhir:entry [
fhir:reference [ fhir:v "CarePlan/CarePlan-min" ]     ] [
fhir:reference [ fhir:v "MedicationRequest/MedicationRequest-min" ]     ] )
  ] ) . #