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
<Procedure xmlns="http://hl7.org/fhir">
<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>