兒童職能治療臨床文件Document - TTL Representation - 復健訓練評估量表實作指引(Rehabilitation Training Scale Implementation Guide) v0.1.0

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 - TTL Representation

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <https://loinc.org/rdf/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix sct: <http://snomed.info/id/> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:Bundle ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "ChildBundle"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Bundle-document-twcore"^^xsd:anyURI ;
fhir:l <https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Bundle-document-twcore>     ] )
  ] ; # 
  fhir:identifier [
fhir:system [
fhir:v "http://build.fhir.org/ig/Kimsber/Rehab-IG/Bundle/ChildBundle"^^xsd:anyURI ;
fhir:l <http://build.fhir.org/ig/Kimsber/Rehab-IG/Bundle/ChildBundle>     ] ;
fhir:value [ fhir:v "child-bundle" ]
  ] ; # 
  fhir:type [ fhir:v "document"] ; # 
  fhir:timestamp [ fhir:v "2025-12-26T00:00:00+08:00"^^xsd:dateTime] ; # 
  fhir:entry ( [
fhir:fullUrl [
fhir:v "https://build.fhir.org/ig/Kimsber/Rehab-IG/Composition/ChildDocumentComposition"^^xsd:anyURI ;
fhir:l <https://build.fhir.org/ig/Kimsber/Rehab-IG/Composition/ChildDocumentComposition>     ] ;
    ( fhir:resource <https://build.fhir.org/ig/Kimsber/Rehab-IG/Composition/ChildDocumentComposition> )
  ] [
fhir:fullUrl [
fhir:v "https://build.fhir.org/ig/Kimsber/Rehab-IG/Patient/stroke-patient-001"^^xsd:anyURI ;
fhir:l <https://build.fhir.org/ig/Kimsber/Rehab-IG/Patient/stroke-patient-001>     ] ;
    ( fhir:resource <https://build.fhir.org/ig/Kimsber/Rehab-IG/Patient/stroke-patient-001> )
  ] [
fhir:fullUrl [
fhir:v "https://build.fhir.org/ig/Kimsber/Rehab-IG/Condition/ConditionExample01"^^xsd:anyURI ;
fhir:l <https://build.fhir.org/ig/Kimsber/Rehab-IG/Condition/ConditionExample01>     ] ;
    ( fhir:resource <https://build.fhir.org/ig/Kimsber/Rehab-IG/Condition/ConditionExample01> )
  ] [
fhir:fullUrl [
fhir:v "https://build.fhir.org/ig/Kimsber/Rehab-IG/CarePlan/CarePlanExample01"^^xsd:anyURI ;
fhir:l <https://build.fhir.org/ig/Kimsber/Rehab-IG/CarePlan/CarePlanExample01>     ] ;
    ( fhir:resource <https://build.fhir.org/ig/Kimsber/Rehab-IG/CarePlan/CarePlanExample01> )
  ] [
fhir:fullUrl [
fhir:v "https://build.fhir.org/ig/Kimsber/Rehab-IG/Practitioner/ot-therapist-001"^^xsd:anyURI ;
fhir:l <https://build.fhir.org/ig/Kimsber/Rehab-IG/Practitioner/ot-therapist-001>     ] ;
    ( fhir:resource <https://build.fhir.org/ig/Kimsber/Rehab-IG/Practitioner/ot-therapist-001> )
  ] [
fhir:fullUrl [
fhir:v "https://build.fhir.org/ig/Kimsber/Rehab-IG/Organization/OrganizationExample"^^xsd:anyURI ;
fhir:l <https://build.fhir.org/ig/Kimsber/Rehab-IG/Organization/OrganizationExample>     ] ;
    ( fhir:resource <https://build.fhir.org/ig/Kimsber/Rehab-IG/Organization/OrganizationExample> )
  ] ) . # 

<https://build.fhir.org/ig/Kimsber/Rehab-IG/Composition/ChildDocumentComposition> a fhir:Composition ;
  fhir:id [ fhir:v "ChildDocumentComposition"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Composition-twcore"^^xsd:anyURI ;
fhir:l <https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Composition-twcore>     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div [ fhir:v "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Composition_ChildDocumentComposition\"> </a><h3><b>\"張先生的病摘\"</b></h3><p><b>狀態：</b> \"最終版\"</p><p><b>日期：</b> \"2025-12-26\"</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>"^^rdf:XMLLiteral ]
  ] ; # 
  fhir:status [ fhir:v "final"] ; # 
  fhir:type [
    ( fhir:coding [
a loinc:100495-1 ;
fhir:system [
fhir:v "http://loinc.org"^^xsd:anyURI ;
fhir:l <http://loinc.org>       ] ;
fhir:code [ fhir:v "100495-1" ]     ] )
  ] ; # 
  fhir:category ( [
    ( fhir:coding [
a loinc:47039-3 ;
fhir:system [
fhir:v "http://loinc.org"^^xsd:anyURI ;
fhir:l <http://loinc.org>       ] ;
fhir:code [ fhir:v "47039-3" ]     ] )
  ] ) ; # 
  fhir:subject [
fhir:l fhir:Patient/stroke-patient-001 ;
fhir:reference [ fhir:v "Patient/stroke-patient-001" ]
  ] ; # 
  fhir:date [ fhir:v "2025-12-26T10:30:00Z"^^xsd:dateTime] ; # 
  fhir:author ( [
fhir:l fhir:Practitioner/ot-therapist-001 ;
fhir:reference [ fhir:v "Practitioner/ot-therapist-001" ]
  ] ) ; # 
  fhir:title [ fhir:v "兒童職能治療接案紀錄範本"] ; # 
  fhir:confidentiality [ fhir:v "R"] ; # 
  fhir:attester ( [
fhir:mode [ fhir:v "personal" ] ;
fhir:time [ fhir:v "2023-09-10T11:00:00Z"^^xsd:dateTime ] ;
fhir:party [
fhir:l fhir:Practitioner/ot-therapist-001 ;
fhir:reference [ fhir:v "Practitioner/ot-therapist-001" ]     ]
  ] ) ; # 
  fhir:custodian [
fhir:l fhir:Organization/OrganizationExample ;
fhir:reference [ fhir:v "Organization/OrganizationExample" ]
  ] ; # 
  fhir:event ( [
fhir:period [
fhir:start [ fhir:v "2025-12-26T10:30:00Z"^^xsd:dateTime ] ;
fhir:end [ fhir:v "2025-12-26T13:30:00Z"^^xsd:dateTime ]     ]
  ] ) ; # 
  fhir:section ( [
    ( fhir:entry [
fhir:l fhir:Practitioner/ot-therapist-001 ;
fhir:reference [ fhir:v "Practitioner/ot-therapist-001" ]     ] [
fhir:l fhir:Condition/ConditionExample01 ;
fhir:reference [ fhir:v "Condition/ConditionExample01" ]     ] [
fhir:l fhir:CarePlan/CarePlanExample01 ;
fhir:reference [ fhir:v "CarePlan/CarePlanExample01" ]     ] )
  ] ) . # 

<https://build.fhir.org/ig/Kimsber/Rehab-IG/Patient/stroke-patient-001> a fhir:Patient ;
  fhir:id [ fhir:v "stroke-patient-001"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "https://build.fhir.org/ig/Kimsber/Rehab-IG/StructureDefinition/Patient"^^xsd:anyURI ;
fhir:l <https://build.fhir.org/ig/Kimsber/Rehab-IG/StructureDefinition/Patient>     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div [ fhir:v "<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>"^^rdf:XMLLiteral ]
  ] ; # 
  fhir:identifier ( [
fhir:type [
      ( fhir:coding [
fhir:system [
fhir:v "http://terminology.hl7.org/CodeSystem/v2-0203"^^xsd:anyURI ;
fhir:l <http://terminology.hl7.org/CodeSystem/v2-0203>         ] ;
fhir:code [ fhir:v "NNxxx" ]       ] )     ] ;
fhir:system [
fhir:v "http://www.moi.gov.tw"^^xsd:anyURI ;
fhir:l <http://www.moi.gov.tw>     ] ;
fhir:value [ fhir:v "A123456789" ]
  ] ) ; # 
  fhir:active [ fhir:v true] ; # 
  fhir:name ( [
fhir:use [ fhir:v "official" ] ;
fhir:family [ fhir:v "張" ] ;
    ( fhir:given [ fhir:v "先生" ] )
  ] ) ; # 
  fhir:gender [ fhir:v "male"] ; # 
  fhir:birthDate [ fhir:v "1965-03-15"^^xsd:date] ; # 
  fhir:address ( [
    ( fhir:extension [
fhir:url [
fhir:v "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-section"^^xsd:anyURI ;
fhir:l <https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-section>       ] ;
fhir:value [
a fhir:String ;
fhir:v "五段"       ]     ] [
fhir:url [
fhir:v "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-lane"^^xsd:anyURI ;
fhir:l <https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-lane>       ] ;
fhir:value [
a fhir:String ;
fhir:v "609巷"       ]     ] [
fhir:url [
fhir:v "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-number"^^xsd:anyURI ;
fhir:l <https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-number>       ] ;
fhir:value [
a fhir:String ;
fhir:v "16號"       ]     ] [
fhir:url [
fhir:v "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-floor"^^xsd:anyURI ;
fhir:l <https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-floor>       ] ;
fhir:value [
a fhir:String ;
fhir:v "6樓之11"       ]     ] ) ;
    ( fhir:line [ fhir:v "重新路" ] ) ;
fhir:city [ fhir:v "三重區" ] ;
fhir:district [ fhir:v "新北市" ] ;
fhir:postalCode [
      ( fhir:extension [
fhir:url [
fhir:v "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-postal-code"^^xsd:anyURI ;
fhir:l <https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-postal-code>         ] ;
fhir:value [
a fhir:CodeableConcept ;
          ( fhir:coding [
fhir:system [
fhir:v "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/postal-code6-tw"^^xsd:anyURI ;
fhir:l <https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/postal-code6-tw>             ] ;
fhir:code [ fhir:v "241408" ]           ] )         ]       ] )     ] ;
fhir:country [ fhir:v "臺灣(TW)" ]
  ] ) . # 

<https://build.fhir.org/ig/Kimsber/Rehab-IG/Condition/ConditionExample01> a fhir:Condition ;
  fhir:id [ fhir:v "ConditionExample01"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Condition-twcore"^^xsd:anyURI ;
fhir:l <https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Condition-twcore>     ] )
  ] ; # 
  fhir:language [ fhir:v "zh-TW"] ; # 
  fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div [ fhir:v "<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>"^^rdf:XMLLiteral ]
  ] ; # 
  fhir:clinicalStatus [
    ( fhir:coding [
fhir:system [
fhir:v "http://terminology.hl7.org/CodeSystem/condition-clinical"^^xsd:anyURI ;
fhir:l <http://terminology.hl7.org/CodeSystem/condition-clinical>       ] ;
fhir:code [ fhir:v "active" ]     ] )
  ] ; # 
  fhir:category ( [
    ( fhir:coding [
fhir:system [
fhir:v "http://terminology.hl7.org/CodeSystem/condition-category"^^xsd:anyURI ;
fhir:l <http://terminology.hl7.org/CodeSystem/condition-category>       ] ;
fhir:code [ fhir:v "problem-list-item" ]     ] )
  ] ) ; # 
  fhir:subject [
fhir:l fhir:Patient/stroke-patient-001 ;
fhir:reference [ fhir:v "Patient/stroke-patient-001" ]
  ] ; # 
  fhir:recordedDate [ fhir:v "2025-03-06"^^xsd:date] ; # 
  fhir:recorder [
fhir:l fhir:Practitioner/ot-therapist-001 ;
fhir:reference [ fhir:v "Practitioner/ot-therapist-001" ]
  ] . # 

<https://build.fhir.org/ig/Kimsber/Rehab-IG/CarePlan/CarePlanExample01> a fhir:CarePlan ;
  fhir:id [ fhir:v "CarePlanExample01"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/CarePlan-twcore"^^xsd:anyURI ;
fhir:l <https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/CarePlan-twcore>     ] )
  ] ; # 
  fhir:language [ fhir:v "zh-TW"] ; # 
  fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div [ fhir:v "<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>"^^rdf:XMLLiteral ]
  ] ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:intent [ fhir:v "plan"] ; # 
  fhir:category ( [
    ( fhir:coding [
fhir:system [
fhir:v "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/careplan-category-tw"^^xsd:anyURI ;
fhir:l <https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/careplan-category-tw>       ] ;
fhir:code [ fhir:v "assess-plan" ]     ] ) ;
fhir:text [ fhir:v "評估和計劃治療" ]
  ] ) ; # 
  fhir:subject [
fhir:l fhir:Patient/stroke-patient-001 ;
fhir:reference [ fhir:v "Patient/stroke-patient-001" ]
  ] . # 

<https://build.fhir.org/ig/Kimsber/Rehab-IG/Practitioner/ot-therapist-001> a fhir:Practitioner ;
  fhir:id [ fhir:v "ot-therapist-001"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "https://build.fhir.org/ig/Kimsber/Rehab-IG/StructureDefinition/Practitioner"^^xsd:anyURI ;
fhir:l <https://build.fhir.org/ig/Kimsber/Rehab-IG/StructureDefinition/Practitioner>     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div [ fhir:v "<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> \"李小姐\"</p><p><b>專科：</b> \"職能治療師\"</p><p><b>執照編號：</b> \"ABC12345\"</p></div>"^^rdf:XMLLiteral ]
  ] ; # 
  fhir:identifier ( [
fhir:system [
fhir:v "http://hospital.mohw.gov.tw/docID"^^xsd:anyURI ;
fhir:l <http://hospital.mohw.gov.tw/docID>     ] ;
fhir:value [ fhir:v "ABC12345" ]
  ] ) ; # 
  fhir:active [ fhir:v true] ; # 
  fhir:name ( [
fhir:use [ fhir:v "official" ] ;
fhir:family [ fhir:v "李" ] ;
    ( fhir:given [ fhir:v "小姐" ] )
  ] ) ; # 
  fhir:qualification ( [
fhir:code [
      ( fhir:coding [
a sct:224609002 ;
fhir:system [
fhir:v "http://snomed.info/sct"^^xsd:anyURI ;
fhir:l <http://snomed.info/sct>         ] ;
fhir:code [ fhir:v "224609002" ] ;
fhir:display [ fhir:v "Complementary health worker" ]       ] ) ;
fhir:text [ fhir:v "職能治療師" ]     ] ;
fhir:issuer [
fhir:display [ fhir:v "台灣職能治療師公會" ]     ]
  ] ) . # 

<https://build.fhir.org/ig/Kimsber/Rehab-IG/Organization/OrganizationExample> a fhir:Organization ;
  fhir:id [ fhir:v "OrganizationExample"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "https://build.fhir.org/ig/Kimsber/Rehab-IG/StructureDefinition/Organization"^^xsd:anyURI ;
fhir:l <https://build.fhir.org/ig/Kimsber/Rehab-IG/StructureDefinition/Organization>     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div [ fhir:v "<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> \"台灣健康醫院\"</p><p><b>機構代碼：</b> \"XYZ54321\"</p><p><b>聯絡電話：</b> \"02-22765566\"</p></div>"^^rdf:XMLLiteral ]
  ] ; # 
  fhir:identifier ( [
fhir:system [
fhir:v "http://hospital.mohw.gov.tw/orgID"^^xsd:anyURI ;
fhir:l <http://hospital.mohw.gov.tw/orgID>     ] ;
fhir:value [ fhir:v "XYZ54321" ]
  ] ) ; # 
  fhir:active [ fhir:v true] ; # 
  fhir:name [ fhir:v "台灣健康醫院"] ; # 
  fhir:telecom ( [
fhir:system [ fhir:v "phone" ] ;
fhir:value [ fhir:v "02-22765566" ]
  ] ) ; # 
  fhir:address ( [
    ( fhir:line [ fhir:v "123 健康路" ] ) ;
fhir:city [ fhir:v "臺北市" ] ;
fhir:state [ fhir:v "中正區" ] ;
fhir:postalCode [ fhir:v "100" ]
  ] ) . #