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

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Narrative

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

望診

狀態：Final ( ObservationStatus#final)

項目：Finding by inspection (simple observation) ( SNOMED CT Code#118243007)

病人：Patient/PatientTWCM-min "陳美真"

紀錄時間：2010-10-10T17:30:00-05:00

望診描述：神清，面色萎黃，形體偏瘦

病人舌象：
苔白（Coating of mucous membrane of tongue ( 病人舌象#698193000) ）
舌淡紅，舌邊有齒痕（此描述無法對應至單一SNOMED CT代碼，故僅記錄文字）

望診分類紀錄：
精神／意識／行為／情緒／性格(望神)：神疲 ( 中醫臨床表現詞彙#神疲)
頭面部(望)：面色萎黃 ( 中醫臨床表現詞彙#面色萎黃)

就醫事件：Encounter/EncounterTWCM-min

Source1

{
  "resourceType": "Observation",
  "id": "ObservationInspectionTWCM-min",
  "meta": {
    "profile": [
      "https://www.nricm.edu.tw/twcm/StructureDefinition/observationinspection-twcm"
    ]
  },
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "status": "final",
  "code": {
    "coding": [
      {
        "system": "http://snomed.info/sct",
        "code": "118243007",
        "display": "Finding by inspection (simple observation)"
      }
    ]
  },
  "subject": {
    "reference": "Patient/PatientTWCM-min"
  },
  "encounter": {
    "reference": "Encounter/EncounterTWCM-min"
  },
  "effectiveDateTime": "2010-10-10T17:30:00-05:00",
  "valueString": "神清，面色萎黃，形體偏瘦",
  "component": [
    {
      "code": {
        "coding": [
          {
            "system": "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-fourdiagnosis-category",
            "code": "望神",
            "display": "精神／意識／行為／情緒／性格(望神)"
          }
        ]
      },
      "valueCodeableConcept": {
        "coding": [
          {
            "system": "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-clinicalfinding",
            "code": "神疲",
            "display": "神疲"
          }
        ],
        "text": "神疲"
      }
    },
    {
      "code": {
        "coding": [
          {
            "system": "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-fourdiagnosis-category",
            "code": "望頭面",
            "display": "頭面部(望)"
          }
        ]
      },
      "valueCodeableConcept": {
        "coding": [
          {
            "system": "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-clinicalfinding",
            "code": "面色萎黃",
            "display": "面色萎黃"
          }
        ],
        "text": "面色萎黃"
      }
    },
    {
      "code": {
        "coding": [
          {
            "system": "http://snomed.info/sct",
            "code": "249378009",
            "display": "Tongue finding"
          }
        ]
      },
      "valueCodeableConcept": {
        "coding": [
          {
            "system": "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-tonguecondition",
            "code": "698193000",
            "display": "Coating of mucous membrane of tongue"
          }
        ],
        "text": "苔白"
      }
    },
    {
      "code": {
        "coding": [
          {
            "system": "http://snomed.info/sct",
            "code": "249378009",
            "display": "Tongue finding"
          }
        ]
      },
      "valueCodeableConcept": {
        "text": "舌淡紅，舌邊有齒痕"
      }
    }
  ]
}