復健訓練評估量表實作指引(Rehabilitation Training Scale Implementation Guide)
0.1.0 - ci-build

復健訓練評估量表實作指引(Rehabilitation Training Scale Implementation Guide), published by Kimsber. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Kimsber/Rehab-IG/ and changes regularly. See the Directory of published versions

: 兒童職能治療臨床文件Document - JSON Representation

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{
  "resourceType" : "Bundle",
  "id" : "ChildBundle",
  "meta" : {
    "profile" : [
      🔗 "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Bundle-document-twcore"
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  "identifier" : {
    "system" : "http://build.fhir.org/ig/Kimsber/Rehab-IG/Bundle/ChildBundle",
    "value" : "child-bundle"
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  "type" : "document",
  "timestamp" : "2025-12-26T00:00:00+08:00",
  "entry" : [
    {
      "fullUrl" : "https://build.fhir.org/ig/Kimsber/Rehab-IG/Composition/ChildDocumentComposition",
      "resource" : {
        "resourceType" : "Composition",
        "id" : "ChildDocumentComposition",
        "meta" : {
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        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Composition_ChildDocumentComposition\"> </a><h3><b>&quot;張先生的病摘&quot;</b></h3><p><b>狀態:</b> &quot;最終版&quot;</p><p><b>日期:</b> &quot;2025-12-26&quot;</p><p><b>臨床意義:</b> 本文件包含病人的醫療紀錄、診斷及用藥資訊</p></div>"
        },
        "status" : "final",
        "type" : {
          "coding" : [
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              "system" : "http://loinc.org",
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                "system" : "http://loinc.org",
                "code" : "47039-3"
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            ]
          }
        ],
        "subject" : {
          🔗 "reference" : "Patient/stroke-patient-001"
        },
        "date" : "2025-12-26T10:30:00Z",
        "author" : [
          {
            🔗 "reference" : "Practitioner/ot-therapist-001"
          }
        ],
        "title" : "兒童職能治療接案紀錄範本",
        "confidentiality" : "R",
        "attester" : [
          {
            "mode" : "personal",
            "time" : "2023-09-10T11:00:00Z",
            "party" : {
              🔗 "reference" : "Practitioner/ot-therapist-001"
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        ],
        "custodian" : {
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              "start" : "2025-12-26T10:30:00Z",
              "end" : "2025-12-26T13:30:00Z"
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        "section" : [
          {
            "entry" : [
              {
                🔗 "reference" : "Practitioner/ot-therapist-001"
              },
              {
                🔗 "reference" : "Condition/ConditionExample01"
              },
              {
                🔗 "reference" : "CarePlan/CarePlanExample01"
              }
            ]
          }
        ]
      }
    },
    {
      "fullUrl" : "https://build.fhir.org/ig/Kimsber/Rehab-IG/Patient/stroke-patient-001",
      "resource" : {
        "resourceType" : "Patient",
        "id" : "stroke-patient-001",
        "meta" : {
          "profile" : [
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        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Patient_stroke-patient-001\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Patient stroke-patient-001</b></p><a name=\"stroke-patient-001\"> </a><a name=\"hcstroke-patient-001\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-Patient.html\">根據醫院實際病人範例進行資料定義</a></p></div><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">先生 張 (official) Male, DoB: 1965-03-15 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code)</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"Record is active\">Active:</td><td colspan=\"3\">true</td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Ways to contact the Patient\">Contact Detail</td><td colspan=\"3\">重新路 三重區 null 臺灣(TW) </td></tr></table></div>"
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            "system" : "http://www.moi.gov.tw",
            "value" : "A123456789"
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        ],
        "active" : true,
        "name" : [
          {
            "use" : "official",
            "family" : "張",
            "given" : [
              "先生"
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          }
        ],
        "gender" : "male",
        "birthDate" : "1965-03-15",
        "address" : [
          {
            "extension" : [
              {
                "url" : "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-section",
                "valueString" : "五段"
              },
              {
                "url" : "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-lane",
                "valueString" : "609巷"
              },
              {
                "url" : "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-number",
                "valueString" : "16號"
              },
              {
                "url" : "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-floor",
                "valueString" : "6樓之11"
              }
            ],
            "line" : [
              "重新路"
            ],
            "city" : "三重區",
            "district" : "新北市",
            "_postalCode" : {
              "extension" : [
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                  "url" : "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-postal-code",
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                        "system" : "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/postal-code6-tw",
                        "code" : "241408"
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                    ]
                  }
                }
              ]
            },
            "country" : "臺灣(TW)"
          }
        ]
      }
    },
    {
      "fullUrl" : "https://build.fhir.org/ig/Kimsber/Rehab-IG/Condition/ConditionExample01",
      "resource" : {
        "resourceType" : "Condition",
        "id" : "ConditionExample01",
        "meta" : {
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        "language" : "zh-TW",
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Condition_ConditionExample01\"> </a><p><b>臨床觀察</b></p><p>個案在案父母陪同下,可進入治療室接受指令完成評估 ()。評估過程較沒自信,每個動作揭已眼神向父母或治療師確認自己是否答對,全身肌肉低張力影響握筆姿勢、運筆及精細操作穩定度。</p><p>個案父母表示家中上有兩個哥哥,在家和案兄互動沒有困難,案母為中國籍,之前曾帶個案回中國就讀幼兒園約3個月,而後返回臺灣就讀中班,在學校中較我行我素少和同儕互動,學東西較慢,由老師建議就診早療。</p></div>"
        },
        "clinicalStatus" : {
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              "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical",
              "code" : "active"
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          ]
        },
        "category" : [
          {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/condition-category",
                "code" : "problem-list-item"
              }
            ]
          }
        ],
        "subject" : {
          🔗 "reference" : "Patient/stroke-patient-001"
        },
        "recordedDate" : "2025-03-06",
        "recorder" : {
          🔗 "reference" : "Practitioner/ot-therapist-001"
        }
      }
    },
    {
      "fullUrl" : "https://build.fhir.org/ig/Kimsber/Rehab-IG/CarePlan/CarePlanExample01",
      "resource" : {
        "resourceType" : "CarePlan",
        "id" : "CarePlanExample01",
        "meta" : {
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            🔗 "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/CarePlan-twcore"
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        },
        "language" : "zh-TW",
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"CarePlan_CarePlanExample01\"> </a><p><b>Home programs</b></p><ol><li>建議練習點點連線畫斜線、十字、方形,框框中著色、迷宮或描虛線運筆、仿疊仿組積木、使用剪刀剪方形圖形,增進精細動作發展。</li><li>建議每天練習爬樓梯、攀爬遊樂設施、手走路、趴在椅子上撐手、投籃、捏衣夾夾菜夾、使用蠟筆著色、組小花片或小樂高積木再拆開,增進肌肉力量以及耐力的活動。</li><li>練習在生活中動作引導穿鞋子襪子上衣、搓洗雙手擦乾,增進身邊處理能力。</li><li>建議引導個案和同學打招呼、揮手再見、一起排隊輪流合作、交換或一起玩玩具,增進人際互動能力。</li><li>已在居家附近職能治療,建議持續治療,並配合治療師加強居家訓練活動。</li></ol></div>"
        },
        "status" : "active",
        "intent" : "plan",
        "category" : [
          {
            "coding" : [
              {
                "system" : "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/careplan-category-tw",
                "code" : "assess-plan"
              }
            ],
            "text" : "評估和計劃治療"
          }
        ],
        "subject" : {
          🔗 "reference" : "Patient/stroke-patient-001"
        }
      }
    },
    {
      "fullUrl" : "https://build.fhir.org/ig/Kimsber/Rehab-IG/Practitioner/ot-therapist-001",
      "resource" : {
        "resourceType" : "Practitioner",
        "id" : "ot-therapist-001",
        "meta" : {
          "profile" : [
            🔗 "https://build.fhir.org/ig/Kimsber/Rehab-IG/StructureDefinition/Practitioner"
          ]
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Practitioner_ot-therapist-001\"> </a><h3><b>醫療提供者</b></h3><p><b>姓名:</b> &quot;李小姐&quot;</p><p><b>專科:</b> &quot;職能治療師&quot;</p><p><b>執照編號:</b> &quot;ABC12345&quot;</p></div>"
        },
        "identifier" : [
          {
            "system" : "http://hospital.mohw.gov.tw/docID",
            "value" : "ABC12345"
          }
        ],
        "active" : true,
        "name" : [
          {
            "use" : "official",
            "family" : "李",
            "given" : [
              "小姐"
            ]
          }
        ],
        "qualification" : [
          {
            "code" : {
              "coding" : [
                {
                  "system" : "http://snomed.info/sct",
                  "code" : "224609002",
                  "display" : "Complementary health worker"
                }
              ],
              "text" : "職能治療師"
            },
            "issuer" : {
              "display" : "台灣職能治療師公會"
            }
          }
        ]
      }
    },
    {
      "fullUrl" : "https://build.fhir.org/ig/Kimsber/Rehab-IG/Organization/OrganizationExample",
      "resource" : {
        "resourceType" : "Organization",
        "id" : "OrganizationExample",
        "meta" : {
          "profile" : [
            🔗 "https://build.fhir.org/ig/Kimsber/Rehab-IG/StructureDefinition/Organization"
          ]
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Organization_OrganizationExample\"> </a><h3><b>醫療機構</b></h3><p><b>機構名稱:</b> &quot;台灣健康醫院&quot;</p><p><b>機構代碼:</b> &quot;XYZ54321&quot;</p><p><b>聯絡電話:</b> &quot;02-22765566&quot;</p></div>"
        },
        "identifier" : [
          {
            "system" : "http://hospital.mohw.gov.tw/orgID",
            "value" : "XYZ54321"
          }
        ],
        "active" : true,
        "name" : "台灣健康醫院",
        "telecom" : [
          {
            "system" : "phone",
            "value" : "02-22765566"
          }
        ],
        "address" : [
          {
            "line" : [
              "123 健康路"
            ],
            "city" : "臺北市",
            "state" : "中正區",
            "postalCode" : "100"
          }
        ]
      }
    }
  ]
}