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 - XML Representation

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    <Bundle xmlns="http://hl7.org/fhir">
      <id value="ChildBundle"/>
      <meta>
        <profile
                 value="https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Bundle-document-twcore"/>
      </meta>
      <identifier>
        <system
                value="http://build.fhir.org/ig/Kimsber/Rehab-IG/Bundle/ChildBundle"/>
        <value value="child-bundle"/>
      </identifier>
      <type value="document"/>
      <timestamp value="2025-12-26T00:00:00+08:00"/>
      <entry>
        <fullUrl
                 value="https://build.fhir.org/ig/Kimsber/Rehab-IG/Composition/ChildDocumentComposition"/>
        <resource>
          <Composition>
            <id value="ChildDocumentComposition"/>
            <meta>
              <profile
                       value="https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Composition-twcore"/>
            </meta>
            <text>
              <status value="generated"/>
              <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>
            </text>
            <status value="final"/>
            <type>
              <coding>
                <system value="http://loinc.org"/>
                <code value="100495-1"/>
              </coding>
            </type>
            <category>
              <coding>
                <system value="http://loinc.org"/>
                <code value="47039-3"/>
              </coding>
            </category>
            <subject>🔗
              <reference value="Patient/stroke-patient-001"/>
            </subject>
            <date value="2025-12-26T10:30:00Z"/>
            <author>🔗
              <reference value="Practitioner/ot-therapist-001"/>
            </author>
            <title value="兒童職能治療接案紀錄範本"/>
            <confidentiality value="R"/>
            <attester>
              <mode value="personal"/>
              <time value="2023-09-10T11:00:00Z"/>
              <party>🔗
                <reference value="Practitioner/ot-therapist-001"/>
              </party>
            </attester>
            <custodian>🔗
              <reference value="Organization/OrganizationExample"/>
            </custodian>
            <event>
              <period>
                <start value="2025-12-26T10:30:00Z"/>
                <end value="2025-12-26T13:30:00Z"/>
              </period>
            </event>
            <section>
              <entry>🔗
                <reference value="Practitioner/ot-therapist-001"/>
              </entry>
              <entry>🔗
                <reference value="Condition/ConditionExample01"/>
              </entry>
              <entry>🔗
                <reference value="CarePlan/CarePlanExample01"/>
              </entry>
            </section>
          </Composition>
        </resource>
      </entry>
      <entry>
        <fullUrl
                 value="https://build.fhir.org/ig/Kimsber/Rehab-IG/Patient/stroke-patient-001"/>
        <resource>
          <Patient>
            <id value="stroke-patient-001"/>
            <meta>
              <profile
                       value="https://build.fhir.org/ig/Kimsber/Rehab-IG/StructureDefinition/Patient"/>
            </meta>
            <text>
              <status value="generated"/>
              <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>
            </text>
            <identifier>
              <type>
                <coding>
                  <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
                  <code value="NNxxx"/>
                </coding>
              </type>
              <system value="http://www.moi.gov.tw"/>
              <value value="A123456789"/>
            </identifier>
            <active value="true"/>
            <name>
              <use value="official"/>
              <family value="張"/>
              <given value="先生"/>
            </name>
            <gender value="male"/>
            <birthDate value="1965-03-15"/>
            <address>
              <extension
                         url="https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-section">
                <valueString value="五段"/>
              </extension>
              <extension
                         url="https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-lane">
                <valueString value="609巷"/>
              </extension>
              <extension
                         url="https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-number">
                <valueString value="16號"/>
              </extension>
              <extension
                         url="https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-floor">
                <valueString value="6樓之11"/>
              </extension>
              <line value="重新路"/>
              <city value="三重區"/>
              <district value="新北市"/>
              <postalCode>
                <extension
                           url="https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-postal-code">
                  <valueCodeableConcept>
                    <coding>
                      <system
                              value="https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/postal-code6-tw"/>
                      <code value="241408"/>
                    </coding>
                  </valueCodeableConcept>
                </extension>
              </postalCode>
              <country value="臺灣(TW)"/>
            </address>
          </Patient>
        </resource>
      </entry>
      <entry>
        <fullUrl
                 value="https://build.fhir.org/ig/Kimsber/Rehab-IG/Condition/ConditionExample01"/>
        <resource>
          <Condition>
            <id value="ConditionExample01"/>
            <meta>
              <profile
                       value="https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Condition-twcore"/>
            </meta>
            <language value="zh-TW"/>
            <text>
              <status value="generated"/>
              <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>
            </text>
            <clinicalStatus>
              <coding>
                <system
                        value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
                <code value="active"/>
              </coding>
            </clinicalStatus>
            <category>
              <coding>
                <system
                        value="http://terminology.hl7.org/CodeSystem/condition-category"/>
                <code value="problem-list-item"/>
              </coding>
            </category>
            <subject>🔗
              <reference value="Patient/stroke-patient-001"/>
            </subject>
            <recordedDate value="2025-03-06"/>
            <recorder>🔗
              <reference value="Practitioner/ot-therapist-001"/>
            </recorder>
          </Condition>
        </resource>
      </entry>
      <entry>
        <fullUrl
                 value="https://build.fhir.org/ig/Kimsber/Rehab-IG/CarePlan/CarePlanExample01"/>
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          <CarePlan>
            <id value="CarePlanExample01"/>
            <meta>
              <profile
                       value="https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/CarePlan-twcore"/>
            </meta>
            <language value="zh-TW"/>
            <text>
              <status value="generated"/>
              <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>
            </text>
            <status value="active"/>
            <intent value="plan"/>
            <category>
              <coding>
                <system
                        value="https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/careplan-category-tw"/>
                <code value="assess-plan"/>
              </coding>
              <text value="評估和計劃治療"/>
            </category>
            <subject>🔗
              <reference value="Patient/stroke-patient-001"/>
            </subject>
          </CarePlan>
        </resource>
      </entry>
      <entry>
        <fullUrl
                 value="https://build.fhir.org/ig/Kimsber/Rehab-IG/Practitioner/ot-therapist-001"/>
        <resource>
          <Practitioner>
            <id value="ot-therapist-001"/>
            <meta>
              <profile
                       value="https://build.fhir.org/ig/Kimsber/Rehab-IG/StructureDefinition/Practitioner"/>
            </meta>
            <text>
              <status value="generated"/>
              <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>
            </text>
            <identifier>
              <system value="http://hospital.mohw.gov.tw/docID"/>
              <value value="ABC12345"/>
            </identifier>
            <active value="true"/>
            <name>
              <use value="official"/>
              <family value="李"/>
              <given value="小姐"/>
            </name>
            <qualification>
              <code>
                <coding>
                  <system value="http://snomed.info/sct"/>
                  <code value="224609002"/>
                  <display value="Complementary health worker"/>
                </coding>
                <text value="職能治療師"/>
              </code>
              <issuer>
                <display value="台灣職能治療師公會"/>
              </issuer>
            </qualification>
          </Practitioner>
        </resource>
      </entry>
      <entry>
        <fullUrl
                 value="https://build.fhir.org/ig/Kimsber/Rehab-IG/Organization/OrganizationExample"/>
        <resource>
          <Organization>
            <id value="OrganizationExample"/>
            <meta>
              <profile
                       value="https://build.fhir.org/ig/Kimsber/Rehab-IG/StructureDefinition/Organization"/>
            </meta>
            <text>
              <status value="generated"/>
              <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>
            </text>
            <identifier>
              <system value="http://hospital.mohw.gov.tw/orgID"/>
              <value value="XYZ54321"/>
            </identifier>
            <active value="true"/>
            <name value="台灣健康醫院"/>
            <telecom>
              <system value="phone"/>
              <value value="02-22765566"/>
            </telecom>
            <address>
              <line value="123 健康路"/>
              <city value="臺北市"/>
              <state value="中正區"/>
              <postalCode value="100"/>
            </address>
          </Organization>
        </resource>
      </entry>
    </Bundle>