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Packagetw.gov.mohw.nricm.twcm
Resource TypeObservation
IdObservation-ObservationInquiryTWCM-min.json
FHIR VersionR4

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Narrative

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

問診

狀態：Final ( ObservationStatus#final)

項目：Finding reported by subject or history provider ( SNOMED CT Code#418799008)

病人：Patient/PatientTWCM-min "陳美真"

紀錄時間：2010-10-10T17:30:00-05:00

問診描述：惡寒發熱，鼻塞流清涕，納差，大便溏，夜寐尚可

問診分類紀錄：
寒熱(問)：惡寒發熱 ( 中醫臨床表現詞彙#惡寒發熱)
鼻咽部(問)：鼻塞 ( 中醫臨床表現詞彙#鼻塞)
飲食／口味(問)：納呆(納差、納少) ( 中醫臨床表現詞彙#納呆(納差、納少))
大便(問)：大便溏 ( 中醫臨床表現詞彙#大便溏)

就醫事件：Encounter/EncounterTWCM-min

Source1

{
  "resourceType": "Observation",
  "id": "ObservationInquiryTWCM-min",
  "meta": {
    "profile": [
      "https://www.nricm.edu.tw/twcm/StructureDefinition/observationinquiry-twcm"
    ]
  },
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "status": "final",
  "code": {
    "coding": [
      {
        "system": "http://snomed.info/sct",
        "code": "418799008",
        "display": "Finding reported by subject or history provider"
      }
    ]
  },
  "subject": {
    "reference": "Patient/PatientTWCM-min"
  },
  "encounter": {
    "reference": "Encounter/EncounterTWCM-min"
  },
  "effectiveDateTime": "2010-10-10T17:30:00-05:00",
  "valueString": "惡寒發熱，鼻塞流清涕，納差，大便溏，夜寐尚可",
  "component": [
    {
      "code": {
        "coding": [
          {
            "system": "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-fourdiagnosis-category",
            "code": "問寒熱",
            "display": "寒熱(問)"
          }
        ]
      },
      "valueCodeableConcept": {
        "coding": [
          {
            "system": "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-clinicalfinding",
            "code": "惡寒發熱",
            "display": "惡寒發熱"
          }
        ],
        "text": "惡寒發熱"
      }
    },
    {
      "code": {
        "coding": [
          {
            "system": "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-fourdiagnosis-category",
            "code": "問鼻咽",
            "display": "鼻咽部(問)"
          }
        ]
      },
      "valueCodeableConcept": {
        "coding": [
          {
            "system": "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-clinicalfinding",
            "code": "鼻塞",
            "display": "鼻塞"
          }
        ],
        "text": "鼻塞"
      }
    },
    {
      "code": {
        "coding": [
          {
            "system": "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-fourdiagnosis-category",
            "code": "問飲食口味",
            "display": "飲食／口味(問)"
          }
        ]
      },
      "valueCodeableConcept": {
        "coding": [
          {
            "system": "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-clinicalfinding",
            "code": "納呆(納差、納少)",
            "display": "納呆(納差、納少)"
          }
        ],
        "text": "納呆(納差、納少)"
      }
    },
    {
      "code": {
        "coding": [
          {
            "system": "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-fourdiagnosis-category",
            "code": "問大便",
            "display": "大便(問)"
          }
        ]
      },
      "valueCodeableConcept": {
        "coding": [
          {
            "system": "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-clinicalfinding",
            "code": "大便溏",
            "display": "大便溏"
          }
        ],
        "text": "大便溏"
      }
    }
  ]
}