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Narrative

Note: links and images are rebased to the (stated) source

Source1

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