FHIR IG analytics| Package | tw.gov.mohw.nricm.twcm |
| Resource Type | Composition |
| Id | Composition-CompositionTWCM-min.json |
| FHIR Version | R4 |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
病歷表單版本：1
臨床狀態：Final (CompositionStatus#final)
種類：Outpatient Note ( LOINC#34108-1)
病人：Patient/PatientTWCM-min "陳美真"
就醫事件：Encounter/EncounterTWCM-min
文件產生時間：2010-04-21T14:30:00+08:00
醫事機構代碼：OrganizationTWCM-min "3801012567"
醫事機構名稱：OrganizationTWCM-min "捷達世中醫診所"
文件標題：中醫門診單
文件敏感性：normal ( v3 Code System Confidentiality#N)
病摘小節內容：
section[PatientInformation]： Patient/PatientTWCM-min
section[AllergyIntolerance]： AllergyIntolerance/AllergyIntoleranceTWCM-min
section[MedicalHistory]： Condition/ConditionMedicalHistoryTWCM-min、Condition/ConditionMedicalHistoryTWCM-menstrual、Condition/ConditionMedicalHistoryTWCM-obstetric、Condition/ConditionMedicalHistoryTWCM-pediatric
section[ConditionMajorIllness]： Observation/ObservationMajorIllnessTWCM-min
section： Condition/ConditionMajorIllnessTWCM-minsection[Medication]：
section[medication]： Medication/MedicationTWCM-min
section[medication]： Medication/MedicationTWCM-pro
section[medicationrequest]： MedicationRequest/MedicationRequestTWCM-min
section[medicationrequest]： MedicationRequest/MedicationRequestTWCM-prosection[ConditionDiagnosis]：
section[conditiondiagnosis]： Condition/ConditionDiagnosisTWCM-min、Condition/ConditionSyndromeTypeTWCM-min
section[practitioner]： Practitioner/PractitionerTWCM-prosection[PhysicalFindings]： Observation/ObservationPulseConditionTWCM-min、Observation/ObservationPulseConditionTWCM-lefthand
section[PlanOfCare]： CarePlan/CarePlanTWCM-min、Procedure/ProcedureTherapeuticPrinciplesTWCM-min
section[ConditionChiefComplaint]： Condition/ConditionChiefComplaintTWCM-min
section[PresentIllness]： Condition/ConditionMedicalHistoryTWCM-present
section[ObservationVitalSign]： Observation/ObservationVitalSignTWCM-min
section[Procedure]： Procedure/ProcedureTWCM-min
section[Procedure]： Procedure/ProcedureTWCM-minn
section[Procedure]： Procedure/ProcedureTWCM-prosection[ObservationLabResults]：
section[observation]： Observation/ObservationTWCM-min
section[observation]： Observation/ObservationTWCM-pro
section[servicerequest]： ServiceRequest/ServiceRequestTWCM-min
section[servicerequest]： ServiceRequest/ServiceRequestTWCM-pro
section[diagnosticreport]： DiagnosticReport/DiagnosticReportTWCM-min
section[bloodtype]： Observation/ObservationBloodtypeTWCM-minsection[DocumentReference]： DocumentReference/DocumentReferenceTWCM-min
section[FamilyMemberHistory]： FamilyMemberHistory/FamilyMemberHistoryTWCM-min
section[SocialHistory]： Observation/ObservationSocialHistoryTWCM-min
section[occupation]： Observation/ObservationOccupationTWCM-min
section[educationlevel]： Observation/ObservationEducationLevelTWCM-minsection[Objective]：
ClinicalImpression/ClinicalImpressionTWCM-min
Observation/ObservationInspectionTWCM-min
Observation/ObservationListeningSmellingTWCM-min
Observation/ObservationInquiryTWCM-min
Observation/ObservationPalpationTWCM-min
FHIR
FHIRsmith{
"resourceType": "Composition",
"id": "CompositionTWCM-min",
"meta": {
"versionId": "1",
"profile": [
"https://www.nricm.edu.tw/twcm/StructureDefinition/composition-twcm",
"https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Composition-twcore"
]
},
"text": {
"status": "generated",
"div": "<!-- snip (see above) -->"
},
"identifier": {
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "SNO"
}
]
},
"value": "TW.NRICM.Clinic.ChineseMedicine.1"
},
"status": "final",
"type": {
"coding": [
{
"system": "http://loinc.org",
"code": "34108-1",
"display": "Outpatient Note"
}
]
},
"subject": {
"reference": "Patient/PatientTWCM-min"
},
"encounter": {
"reference": "Encounter/EncounterTWCM-min"
},
"date": "2010-04-21T14:30:00+08:00",
"author": [
{
"reference": "Organization/OrganizationTWCM-min"
}
],
"title": "中醫門診單",
"confidentiality": "N",
"section": [
{
"title": "病人資料",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "79191-3",
"display": "Patient demographics panel"
}
]
},
"entry": [
{
"reference": "Patient/PatientTWCM-min"
}
]
},
{
"title": "過敏史",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "48765-2",
"display": "Allergies and adverse reactions Document"
}
]
},
"entry": [
{
"reference": "AllergyIntolerance/AllergyIntoleranceTWCM-min"
}
]
},
{
"title": "病史",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11348-0",
"display": "History of Past illness note"
}
]
},
"entry": [
{
"reference": "Condition/ConditionMedicalHistoryTWCM-min"
},
{
"reference": "Condition/ConditionMedicalHistoryTWCM-menstrual"
},
{
"reference": "Condition/ConditionMedicalHistoryTWCM-obstetric"
},
{
"reference": "Condition/ConditionMedicalHistoryTWCM-pediatric"
}
]
},
{
"title": "重大傷病",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11338-1",
"display": "History of Major illnesses and injuries Narrative"
}
]
},
"entry": [
{
"reference": "Observation/ObservationMajorIllnessTWCM-min"
}
],
"section": [
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11338-1",
"display": "History of Major illnesses and injuries Narrative"
}
]
},
"entry": [
{
"reference": "Condition/ConditionMajorIllnessTWCM-min"
}
]
}
]
},
{
"title": "用藥紀錄",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10160-0",
"display": "History of Medication use Narrative"
}
]
},
"section": [
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "87232-5",
"display": "Medication administration.brief"
}
]
},
"entry": [
{
"reference": "Medication/MedicationTWCM-min"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "87232-5",
"display": "Medication administration.brief"
}
]
},
"entry": [
{
"reference": "Medication/MedicationTWCM-pro"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "57833-6",
"display": "Prescription for medication"
}
]
},
"entry": [
{
"reference": "MedicationRequest/MedicationRequestTWCM-min"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "57833-6",
"display": "Prescription for medication"
}
]
},
"entry": [
{
"reference": "MedicationRequest/MedicationRequestTWCM-pro"
}
]
}
]
},
{
"title": "診斷",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11450-4",
"display": "Problem list - Reported"
}
]
},
"section": [
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "29548-5",
"display": "Diagnosis Narrative"
}
]
},
"entry": [
{
"reference": "Condition/ConditionDiagnosisTWCM-min"
},
{
"reference": "Condition/ConditionSyndromeTypeTWCM-min"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "18600-7",
"display": "Primary practitioner identifier"
}
]
},
"entry": [
{
"reference": "Practitioner/PractitionerTWCM-pro"
}
]
}
]
},
{
"title": "理學檢查發現",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "29545-1",
"display": "Physical findings note"
}
]
},
"entry": [
{
"reference": "Observation/ObservationPulseConditionTWCM-min"
},
{
"reference": "Observation/ObservationPulseConditionTWCM-lefthand"
}
]
},
{
"title": "照護計畫",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "18776-5",
"display": "Plan of care note"
}
]
},
"entry": [
{
"reference": "CarePlan/CarePlanTWCM-min"
},
{
"reference": "Procedure/ProcedureTherapeuticPrinciplesTWCM-min"
}
]
},
{
"title": "病人主訴",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10154-3",
"display": "Chief complaint Narrative - Reported"
}
]
},
"entry": [
{
"reference": "Condition/ConditionChiefComplaintTWCM-min"
}
]
},
{
"title": "現病史",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10164-2",
"display": "History of Present illness Narrative"
}
]
},
"entry": [
{
"reference": "Condition/ConditionMedicalHistoryTWCM-present"
}
]
},
{
"title": "生命徵象",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "8716-3",
"display": "Vital signs note"
}
]
},
"entry": [
{
"reference": "Observation/ObservationVitalSignTWCM-min"
}
]
},
{
"title": "處置或手術",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "29554-3",
"display": "Procedure Narrative"
}
]
},
"entry": [
{
"reference": "Procedure/ProcedureTWCM-min"
},
{
"reference": "Procedure/ProcedureTWCM-minn"
},
{
"reference": "Procedure/ProcedureTWCM-pro"
}
]
},
{
"title": "實驗室檢驗檢查紀錄",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "30954-2",
"display": "Relevant diagnostic tests/laboratory data note"
}
]
},
"section": [
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "19146-0",
"display": "Referral lab test results"
}
]
},
"entry": [
{
"reference": "Observation/ObservationTWCM-min"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "19146-0",
"display": "Referral lab test results"
}
]
},
"entry": [
{
"reference": "Observation/ObservationTWCM-pro"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "77597-3",
"display": "Orders placed Document"
}
]
},
"entry": [
{
"reference": "ServiceRequest/ServiceRequestTWCM-min"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "77597-3",
"display": "Orders placed Document"
}
]
},
"entry": [
{
"reference": "ServiceRequest/ServiceRequestTWCM-pro"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "50398-7",
"display": "Narrative diagnostic report [Interpretation]"
}
]
},
"entry": [
{
"reference": "DiagnosticReport/DiagnosticReportTWCM-min"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "883-9",
"display": "ABO group [Type] in Blood"
}
]
},
"entry": [
{
"reference": "Observation/ObservationBloodtypeTWCM-min"
}
]
}
]
},
{
"title": "健康問題文件",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "75310-3",
"display": "Health concerns Document"
}
]
},
"entry": [
{
"reference": "DocumentReference/DocumentReferenceTWCM-min"
}
]
},
{
"title": "家族史",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10157-6",
"display": "History of family member diseases note"
}
]
},
"entry": [
{
"reference": "FamilyMemberHistory/FamilyMemberHistoryTWCM-min"
}
]
},
{
"title": "個人史",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "29762-2",
"display": "Social history note"
}
]
},
"entry": [
{
"reference": "Observation/ObservationSocialHistoryTWCM-min"
}
],
"section": [
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11341-5",
"display": "History of Occupation"
}
]
},
"entry": [
{
"reference": "Observation/ObservationOccupationTWCM-min"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "82589-3",
"display": "Highest level of education"
}
]
},
"entry": [
{
"reference": "Observation/ObservationEducationLevelTWCM-min"
}
]
}
]
},
{
"title": "望聞問切客觀描述",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "61149-1",
"display": "Objective Narrative"
}
]
},
"entry": [
{
"reference": "ClinicalImpression/ClinicalImpressionTWCM-min"
},
{
"reference": "Observation/ObservationInspectionTWCM-min"
},
{
"reference": "Observation/ObservationListeningSmellingTWCM-min"
},
{
"reference": "Observation/ObservationInquiryTWCM-min"
},
{
"reference": "Observation/ObservationPalpationTWCM-min"
}
]
}
]
}