{ "resourceType" : "Bundle", "id" : "ChildBundle", "meta" : { "profile" : ["https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Bundle-document-twcore"] }, "identifier" : { "system" : "http://build.fhir.org/ig/Kimsber/Rehab-IG/Bundle/ChildBundle", "value" : "child-bundle" }, "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" : { "profile" : ["https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Composition-twcore"] }, "text" : { "status" : "generated", "div" : "

"張先生的病摘"

狀態： "最終版"

日期： "2025-12-26"

臨床意義： 本文件包含病人的醫療紀錄、診斷及用藥資訊

" }, "status" : "final", "type" : { "coding" : [{ "system" : "http://loinc.org", "code" : "100495-1" }] }, "category" : [{ "coding" : [{ "system" : "http://loinc.org", "code" : "47039-3" }] }], "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" } }], "custodian" : { "reference" : "Organization/OrganizationExample" }, "event" : [{ "period" : { "start" : "2025-12-26T10:30:00Z", "end" : "2025-12-26T13:30:00Z" } }], "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" : ["https://build.fhir.org/ig/Kimsber/Rehab-IG/StructureDefinition/Patient"] }, "text" : { "status" : "generated", "div" : "

Generated Narrative: Patient stroke-patient-001

Profile: 根據醫院實際病人範例進行資料定義

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)

Active:true
Contact Detail重新路 三重區 null 臺灣(TW)
" }, "identifier" : [{ "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v2-0203", "code" : "NNxxx" }] }, "system" : "http://www.moi.gov.tw", "value" : "A123456789" }], "active" : true, "name" : [{ "use" : "official", "family" : "張", "given" : ["先生"] }], "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" : [{ "url" : "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-postal-code", "valueCodeableConcept" : { "coding" : [{ "system" : "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/postal-code6-tw", "code" : "241408" }] } }] }, "country" : "臺灣(TW)" }] } }, { "fullUrl" : "https://build.fhir.org/ig/Kimsber/Rehab-IG/Condition/ConditionExample01", "resource" : { "resourceType" : "Condition", "id" : "ConditionExample01", "meta" : { "profile" : ["https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Condition-twcore"] }, "language" : "zh-TW", "text" : { "status" : "generated", "div" : "

臨床觀察

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。

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。

" }, "clinicalStatus" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical", "code" : "active" }] }, "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" : { "profile" : ["https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/CarePlan-twcore"] }, "language" : "zh-TW", "text" : { "status" : "generated", "div" : "

Home programs

  1. 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。
  2. 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。
  3. 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。
  4. 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。
  5. 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。
" }, "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" : "

醫療提供者

姓名： "李小姐"

專科： "職能治療師"

執照編號： "ABC12345"

" }, "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" : "

醫療機構

機構名稱： "台灣健康醫院"

機構代碼： "XYZ54321"

聯絡電話： "02-22765566"

" }, "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" }] } }] }