臺灣長期照顧實作指引(TW LTC IG)
1.0.0 - STU 1.0.0
臺灣長期照顧實作指引(TW LTC IG), published by 經濟部產業發展署. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Lorex/TWLongTermCare_IG_Build/ and changes regularly. See the Directory of published versions
This content is an example of the 長期照顧管理中心個案服務初篩表/轉介單邏輯模型 Logical Model and is not a FHIR Resource
{
"resourceType": "http://ltc-ig.fhir.tw/StructureDefinition/LTCRferralModel",
"patient": {
"patientId": "A123456789",
"name": "陳明慧",
"birthDate": "1955-03-15",
"gender": "female",
"address": "台北市大同區重慶北路三段22號",
"phone": "0912-345-678",
"emergencyContact": {
"name": "陳大明",
"relationship": "配偶",
"phone": "0912-345-679"
}
},
"disability": {
"hasDisabilityCard": true,
"disabilityType": [
"肢體障礙"
],
"disabilityCode": [
"G81.9"
],
"disabilityLevel": [
"中度"
]
},
"medicalConditions": {
"tubeStatus": {
"hasTube": true,
"tubeType": [
"鼻胃管"
]
},
"crushStatus": {
"hasCrush": true,
"crushLocation": [
"薦骨"
],
"crushStage": [
"第二期"
],
"crushSize": [
"3x4公分"
]
}
},
"livingSituation": {
"residenceType": "自宅",
"livingAlone": false,
"housingCondition": "良好",
"accessibility": "部分無障礙"
},
"caregiverSituation": {
"hasCaregiver": true,
"caregiverType": "家屬",
"caregiverNationality": "本國籍",
"caregiverRelationship": "配偶",
"caregiverWorkStatus": "退休"
},
"medicalHistory": {
"primaryDiseases": [
{
"diseaseName": "糖尿病",
"icd10Code": "E11.9",
"diagnosisDate": "2020-01-15",
"currentStatus": "控制良好"
}
]
},
"needsAndProblems": {
"primaryProblems": [
{
"problemDescription": "行動不便,需要協助日常生活",
"problemCategory": "功能障礙"
}
],
"careNeeds": [
{
"needDescription": "居家服務、復健服務",
"needPriority": "高"
}
]
},
"requestedServices": [
{
"serviceType": "居家服務",
"serviceDescription": "日常生活協助",
"serviceFrequency": "每週3次",
"serviceDuration": "6個月"
}
],
"functionalAssessment": {
"adlAssessment": {
"bathing": "需要協助",
"dressing": "需要協助",
"toileting": "需要協助",
"transferring": "完全依賴",
"continence": "需要協助",
"feeding": "需要協助"
},
"iadlAssessment": {
"telephone": "完全依賴",
"shopping": "完全依賴",
"cooking": "完全依賴",
"housekeeping": "完全依賴",
"laundry": "完全依賴",
"transportation": "完全依賴",
"medication": "需要協助",
"finances": "完全依賴"
},
"sofAssessment": {
"weightLoss": true,
"exhaustion": true,
"weakness": true,
"slowWalking": true,
"lowActivity": true
},
"caregiverAssessment": {
"caregiverName": "陳大明",
"caregiverRelationship": "配偶",
"caregiverAge": "65歲",
"caregiverHealth": "良好",
"caregiverWorkStatus": "退休",
"caregiverSupport": "有限"
}
},
"hospitalizationInfo": {
"admissionStatus": "門診",
"hospitalName": "台北市立聯合醫院",
"department": "復健科"
},
"referralInfo": {
"referrerName": "李護理師",
"referrerTitle": "護理師",
"referrerLicense": "N123456789",
"referrerPhone": "02-2555-3000",
"referrerSignature": "李護理師"
},
"organizationInfo": {
"organizationName": "台北市立聯合醫院",
"organizationAddress": "台北市大同區鄭州路145號",
"organizationPhone": "02-2555-3000",
"organizationContact": "李護理師"
},
"submissionDate": "2024-01-20"
}