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



## Resource Content

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  "timestamp" : "2025-12-26T00:00:00+08:00",
  "entry" : [{
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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",
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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",
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    "fullUrl" : "https://build.fhir.org/ig/Kimsber/Rehab-IG/Patient/stroke-patient-001",
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      "id" : "stroke-patient-001",
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        "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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            "code" : "NNxxx"
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        "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"
        },
        {
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          "valueString" : "16號"
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          "valueString" : "6樓之11"
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        "line" : ["重新路"],
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        "district" : "新北市",
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        "country" : "臺灣(TW)"
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        "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>"
      },
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          "code" : "active"
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          "code" : "problem-list-item"
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        "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",
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        "text" : "評估和計劃治療"
      }],
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        "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>"
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      "identifier" : [{
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        "value" : "ABC12345"
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      "name" : [{
        "use" : "official",
        "family" : "李",
        "given" : ["小姐"]
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      "qualification" : [{
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          "coding" : [{
            "system" : "http://snomed.info/sct",
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          "text" : "職能治療師"
        },
        "issuer" : {
          "display" : "台灣職能治療師公會"
        }
      }]
    }
  },
  {
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      "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" : [{
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        "value" : "XYZ54321"
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      "active" : true,
      "name" : "台灣健康醫院",
      "telecom" : [{
        "system" : "phone",
        "value" : "02-22765566"
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      "address" : [{
        "line" : ["123 健康路"],
        "city" : "臺北市",
        "state" : "中正區",
        "postalCode" : "100"
      }]
    }
  }]
}

```
