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Packagetw.gov.mohw.twcore
Resource TypeComposition
IdComposition-com-surgery-example.json
FHIR VersionR4

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Narrative

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

手術摘要報告

臨床狀態：Final (CompositionStatus#final)

種類：Medical records ( LOINC#11503-0)

分類：Surgical operation note ( LOINC#11504-8)

病人：Patient/pat-example "陳加玲"

編輯時間：2023-11-05T14:45:00

報告創建者：Practitioner/pra-dr-example "王依昇"

根據特定技術領域的定義：normal ( v3 Code System Confidentiality#N)

證明準確性：

認證者提供的認證類型：Personal ( CompositionAttestationMode#personal)

被證明的時間：2023-11-05T15:30:00

負責證明的人員：Practitioner/pra-dr-example "王依昇"

負責維護機構：Organization/org-hosp-example "衛生福利部臺北醫院"

正在記錄的臨床服務：

被記錄的主要臨床行為代碼：Surgical ( ActCode#SURG)

文件所涵蓋的時間區間：2023-11-05T12:00:00 ～ 2023-11-05T16:00:00

報告小節內容： Procedure/pro-appendectomy-example

Source1

{
  "resourceType": "Composition",
  "id": "com-surgery-example",
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "status": "final",
  "type": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "11503-0",
        "display": "Medical records"
      }
    ]
  },
  "category": [
    {
      "coding": [
        {
          "system": "http://loinc.org",
          "code": "11504-8"
        }
      ]
    }
  ],
  "subject": {
    "reference": "Patient/pat-example"
  },
  "date": "2023-11-05T14:45:00Z",
  "author": [
    {
      "reference": "Practitioner/pra-dr-example",
      "display": "王依昇"
    }
  ],
  "title": "手術摘要報告",
  "confidentiality": "N",
  "attester": [
    {
      "mode": "personal",
      "time": "2023-11-05T15:30:00Z",
      "party": {
        "reference": "Practitioner/pra-dr-example",
        "display": "王依昇"
      }
    }
  ],
  "custodian": {
    "reference": "Organization/org-hosp-example",
    "display": "衛生福利部臺北醫院"
  },
  "event": [
    {
      "code": [
        {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
              "code": "SURG",
              "display": "Surgical"
            }
          ]
        }
      ],
      "period": {
        "start": "2023-11-05T12:00:00Z",
        "end": "2023-11-05T16:00:00Z"
      }
    }
  ],
  "section": [
    {
      "entry": [
        {
          "reference": "Procedure/pro-appendectomy-example"
        }
      ]
    }
  ]
}