醫查實作指引
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: 出院病歷摘要 - XML Representation

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<Composition xmlns="http://hl7.org/fhir">
  <id value="CompositionDischargeSummary-min"/>
  <meta>
    <profile
             value="https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/composition-dischargesummary-imri"/>
  </meta>
  <text>
    <status value="generated"/>
    <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>
  </text>
  <status value="final"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="18842-5"/>
      <display value="Discharge summary"/>
    </coding>
  </type>
  <subject>🔗 
    <reference value="Patient/Patient-min"/>
  </subject>
  <encounter>🔗 
    <reference value="Encounter/Encounter-min"/>
  </encounter>
  <date value="2024-05-12T14:30:00+08:00"/>
  <author>🔗 
    <reference value="Organization/OrganizationHosp-min"/>
  </author>
  <author>🔗 
    <reference value="Practitioner/Practitioner-min"/>
  </author>
  <title value="出院病歷摘要"/>
  <section>
    <title value="住院臆斷"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="46241-6"/>
        <display value="Hospital admission diagnosis Narrative - Reported"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="Observation/ObservationImpression-min"/>
    </entry>
  </section>
  <section>
    <title value="出院診斷"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="11535-2"/>
        <display value="Hospital discharge Dx Narrative"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="Condition/ConditionDischargeDiagnosis-min"/>
    </entry>
  </section>
  <section>
    <title value="癌症期別"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="22037-6"/>
        <display value="Staging Cancer Narrative"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="Observation/ObservationCancerStaging-min"/>
    </entry>
  </section>
  <section>
    <title value="主訴"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10154-3"/>
        <display value="Chief complaint Narrative - Reported"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="Condition/ConditionChiefComplaint-min"/>
    </entry>
  </section>
  <section>
    <title value="病史"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10164-2"/>
        <display value="History of Present illness Narrative"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="Condition/ConditionPresentIllness-min"/>
    </entry>
  </section>
  <section>
    <title value="理學檢查發現"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="29545-1"/>
        <display value="Physical findings Narrative"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="Observation/ObservationPhysicalExamination-min"/>
    </entry>
  </section>
  <section>
    <title value="檢驗與特殊檢查"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="30954-2"/>
        <display value="Relevant diagnostic tests/laboratory data Narrative"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="Observation/ObservationLaboratory-min"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/ObservationLaboratory-lab"/>
    </entry>
  </section>
  <section>
    <title value="醫療影像檢查"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="18748-4"/>
        <display value="Diagnostic imaging study"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="ImagingStudy/ImagingStudy-min"/>
    </entry>
  </section>
  <section>
    <title value="病理報告"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="22034-3"/>
        <display value="Pathology report Cancer Narrative"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="Observation/ObservationPathologyReport-min"/>
    </entry>
  </section>
  <section>
    <title value="手術日期及方法"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="8724-7"/>
        <display value="Surgical operation note description Narrative"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="Procedure/Procedure-min"/>
    </entry>
  </section>
  <section>
    <title value="住院治療經過"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="8648-8"/>
        <display value="Hospital course Narrative"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="Procedure/ProcedureHospitalCourse-min"/>
    </entry>
    <entry>🔗 
      <reference value="Location/Location-min"/>
    </entry>
  </section>
  <section>
    <title value="合併症與併發症"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="55109-3"/>
        <display value="Complications Document"/>
      </coding>
    </code>
    <entry>🔗 
      <reference
                 value="Condition/ConditionComorbiditiesandComplications-min"/>
    </entry>
  </section>
  <section>
    <title value="出院指示"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="8653-8"/>
        <display value="Hospital Discharge instructions"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="CarePlan/CarePlan-min"/>
    </entry>
    <entry>🔗 
      <reference value="MedicationRequest/MedicationRequest-min"/>
    </entry>
  </section>
</Composition>