臺灣長期照顧實作指引(TW LTC IG)
1.1.0 - STU 1.1.0
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 1.1.0 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
Document Details
Last updated: 2026-09-05 12:01:00+0800
Profile: 在宅急症-摘要文件 Bundle
Final Document at 2026-09-05 12:00:00+0800 by 李示範 (https://example.org/practitioners#HAH-STAFF-1) for 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001) in encounter Encounter: status = finished; class = inpatient encounter (ActCode#IMP); type = 在宅急症照護; period = 2026-09-01 09:00:00+0800 --> 2026-09-05 12:00:00+0800
Document Subject
Generated Narrative: Patient hah-patient
Profile: 在宅急症-個案
王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
| Other Id: | National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code/A123456789 | ||
| Contact Detail |
| ||
| Emergency Contact: |
| ||
| Links: |
| ||
Document Content
Generated Narrative: Composition hah-summary
Profile: 在宅急症-結案與轉銜摘要
status: Final
type: Discharge summary
date: 2026-09-05 12:00:00+0800
author: 李示範 (https://example.org/practitioners#HAH-STAFF-1)
title: 王測試在宅急症結案摘要
custodian: 在宅急症示範醫療機構 (Healthcare Provider) (https://example.org/organizations#HAH-ORG-1)
本次在宅照護完成;包含實地與視訊訪視。
呼吸道感染,療程結束時已解除。
已記錄青黴素過敏及皮疹反應。
示範輸注與取消給藥;不是臨床處方建議。
附體溫與血糖檢驗。
附照護目標、計畫、衛教、同意及設備。
已完成本次會診與檢驗工作;後續回診資訊尚未提供。
Entry 2 - fullUrl = https://example.org/fhir/Patient/hah-patient
Resource Patient:
Generated Narrative: Patient hah-patient
Profile: 在宅急症-個案
王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
Other Id: National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code/A123456789 Contact Detail
- ph: 02-00000000
- 臺北市中正區測試路1號(home)
Emergency Contact:
- 王家屬
- ph: 02-00000001
Links:
- Managing Organization: 在宅急症示範醫療機構 (Healthcare Provider) (https://example.org/organizations#HAH-ORG-1)
Entry 3 - fullUrl = https://example.org/fhir/EpisodeOfCare/hah-episode
Resource EpisodeOfCare:
Generated Narrative: EpisodeOfCare hah-episode
Profile: 在宅急症-收案療程
在宅急症-療程結束原因: 完成治療
identifier:
https://example.org/hah/episodes/HAH-20260901-001status: Finished
type: 在宅急症照護
Diagnoses
Condition Condition 呼吸道感染 patient: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
managingOrganization: 在宅急症示範醫療機構 (Healthcare Provider) (https://example.org/organizations#HAH-ORG-1)
period: 2026-09-01 08:00:00+0800 --> 2026-09-05 12:00:00+0800
Entry 4 - fullUrl = https://example.org/fhir/Encounter/hah-admission
Resource Encounter:
Generated Narrative: Encounter hah-admission
Profile: 在宅急症-整段照護
status: Finished
class: ActCode: IMP (inpatient encounter)
type: 在宅急症照護
subject: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
Participants
Individual 李示範 (https://example.org/practitioners#HAH-STAFF-1) period: 2026-09-01 09:00:00+0800 --> 2026-09-05 12:00:00+0800
Diagnoses
Condition Condition 呼吸道感染 Hospitalizations
DischargeDisposition Home Locations
Location 王測試居住地 (Patient's Residence) serviceProvider: 在宅急症示範醫療機構 (Healthcare Provider) (https://example.org/organizations#HAH-ORG-1)
Entry 5 - fullUrl = https://example.org/fhir/Organization/hah-organization
Resource Organization:
Generated Narrative: Organization hah-organization
Profile: 長期照顧-機構
在宅急症示範醫療機構 (Healthcare Provider) (https://example.org/organizations#HAH-ORG-1)
Type: Healthcare Provider
Entry 6 - fullUrl = https://example.org/fhir/Practitioner/hah-practitioner
Resource Practitioner:
Generated Narrative: Practitioner hah-practitioner
Profile: 長期照顧-照顧服務提供者
李示範 (https://example.org/practitioners#HAH-STAFF-1)
Entry 7 - fullUrl = https://example.org/fhir/Location/hah-location
Resource Location:
Generated Narrative: Location hah-location
Profile: 長期照顧-個案位置監測
王測試居住地 (Patient's Residence)
Status: Active Type: Patient's Residence Address: 臺北市中正區測試路1號
Entry 8 - fullUrl = https://example.org/fhir/Encounter/hah-visit
Resource Encounter:
Generated Narrative: Encounter hah-visit
Profile: 在宅急症-單次訪視
在宅急症-訪視方式: in-person
status: Finished
class: ActCode: HH (home health)
type: 訪視
subject: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
Participants
Individual 李示範 (https://example.org/practitioners#HAH-STAFF-1) period: 2026-09-01 09:00:00+0800 --> 2026-09-01 10:00:00+0800
Locations
Location 王測試居住地 (Patient's Residence) serviceProvider: 在宅急症示範醫療機構 (Healthcare Provider) (https://example.org/organizations#HAH-ORG-1)
Entry 9 - fullUrl = https://example.org/fhir/Encounter/hah-video-visit
Resource Encounter:
Generated Narrative: Encounter hah-video-visit
Profile: 在宅急症-單次訪視
在宅急症-訪視方式: video
status: Finished
class: ActCode: VR (virtual)
type: 訪視
subject: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
Participants
Individual 李示範 (https://example.org/practitioners#HAH-STAFF-1) period: 2026-09-02 09:00:00+0800 --> 2026-09-02 09:15:00+0800
serviceProvider: 在宅急症示範醫療機構 (Healthcare Provider) (https://example.org/organizations#HAH-ORG-1)
Entry 10 - fullUrl = https://example.org/fhir/Condition/hah-condition
Resource Condition:
Generated Narrative: Condition hah-condition
Profile: 在宅急症-診斷與照護問題
clinicalStatus: Resolved
verificationStatus: Confirmed
category: Encounter Diagnosis
code: 呼吸道感染
subject: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
recordedDate: 2026-09-01 09:00:00+0800
Entry 11 - fullUrl = https://example.org/fhir/CareTeam/hah-team
Resource CareTeam:
Generated Narrative: CareTeam hah-team
Profile: 在宅急症-照護團隊
status: Inactive
subject: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
participant
role: 主責醫療人員
member: 李示範 (https://example.org/practitioners#HAH-STAFF-1)
period: 2026-09-01 --> 2026-09-05
participant
role: 共照機構
member: 在宅急症示範醫療機構 (Healthcare Provider) (https://example.org/organizations#HAH-ORG-1)
Entry 12 - fullUrl = https://example.org/fhir/Goal/hah-goal
Resource Goal:
Generated Narrative: Goal hah-goal
Profile: 在宅急症-照護目標
lifecycleStatus: Completed
description: 本次照護期間能由照顧者協助完成居家量測並回報不適情形
subject: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
Targets
Due[x] 2026-09-05
Entry 13 - fullUrl = https://example.org/fhir/CarePlan/hah-plan
Resource CarePlan:
王測試的在宅急症照護計畫,所屬療程 HAH-20260901-001,期間為 2026 年 9 月 1 日至 9 月 5 日,狀態為已完成。處理呼吸道感染問題,目標為協助完成每日量測紀錄;包含血糖檢驗醫囑。
Entry 14 - fullUrl = https://example.org/fhir/ServiceRequest/hah-lab-request
Resource ServiceRequest:
Generated Narrative: ServiceRequest hah-lab-request
Profile: 在宅急症-服務請求
status: Completed
intent: Order
category: 檢驗
code: 血液葡萄糖檢驗
subject: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
authoredOn: 2026-09-01 09:05:00+0800
requester: 李示範 (https://example.org/practitioners#HAH-STAFF-1)
reasonReference: Condition 呼吸道感染
Entry 15 - fullUrl = https://example.org/fhir/ServiceRequest/hah-consult-request
Resource ServiceRequest:
Generated Narrative: ServiceRequest hah-consult-request
Profile: 在宅急症-服務請求
status: Completed
intent: Order
category: 專科照會
code: 專科照會
subject: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
authoredOn: 2026-09-01 09:05:00+0800
requester: 李示範 (https://example.org/practitioners#HAH-STAFF-1)
performer: 李示範 (https://example.org/practitioners#HAH-STAFF-1)
reasonReference: Condition 呼吸道感染
Entry 16 - fullUrl = https://example.org/fhir/Task/hah-task
Resource Task:
Generated Narrative: Task hah-task
Profile: 在宅急症-照護工作
status: Completed
intent: order
code: 檢驗
focus: ServiceRequest 血液葡萄糖檢驗
for: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
executionPeriod: 2026-09-01 09:10:00+0800 --> 2026-09-01 09:20:00+0800
authoredOn: 2026-09-01 09:05:00+0800
requester: 李示範 (https://example.org/practitioners#HAH-STAFF-1)
owner: CareTeam: status = inactive
location: 王測試居住地 (Patient's Residence)
Restrictions
Period 2026-09-01 09:05:00+0800 --> 2026-09-01 10:00:00+0800 Outputs
Type Value[x] 檢驗報告 Diagnostic Report for '血糖檢驗報告' for '->王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)'
Entry 17 - fullUrl = https://example.org/fhir/Specimen/hah-specimen
Resource Specimen:
Generated Narrative: Specimen hah-specimen
Profile: TW Core Specimen
identifier:
https://example.org/specimens/HAH-SPECIMEN-1type: 血液
subject: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
Collections
Collector Collected[x] 李示範 (https://example.org/practitioners#HAH-STAFF-1) 2026-09-01 09:10:00+0800
Entry 18 - fullUrl = https://example.org/fhir/Observation/hah-glucose
Resource Observation:
Generated Narrative: Observation hah-glucose
Profile: 在宅急症-檢驗結果
basedOn: ServiceRequest 血液葡萄糖檢驗
status: Final
category: Laboratory
code: Glucose [Mass/volume] in Blood
subject: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
effective: 2026-09-01 09:10:00+0800
performer: 李示範 (https://example.org/practitioners#HAH-STAFF-1)
value: 110 mg/dL (Details: UCUM codemg/dL = 'mg/dL')
specimen: Specimen: identifier = https://example.org/specimens#HAH-SPECIMEN-1; type = 血液
Entry 19 - fullUrl = https://example.org/fhir/DiagnosticReport/hah-report
Resource DiagnosticReport:
Generated Narrative: DiagnosticReport hah-report
Profile: 在宅急症-檢驗報告
血糖檢驗報告
Subject 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001) Relevant Time 2026-09-01 09:10:00+0800 Reported 2026-09-01 09:20:00+0800 Performer 在宅急症示範醫療機構 (Healthcare Provider) (https://example.org/organizations#HAH-ORG-1) Report Details
Code Value Flags Glucose [Mass/volume] in Blood 110 mg/dL (Details: UCUM codemg/dL = 'mg/dL') Final
Entry 20 - fullUrl = https://example.org/fhir/Observation/hah-temperature
Resource Observation:
Generated Narrative: Observation hah-temperature
Profile: 基礎生理量測-體溫
status: Final
category: Vital Signs
code: Body temperature
subject: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
effective: 2026-09-01 09:10:00+0800
performer: 李示範 (https://example.org/practitioners#HAH-STAFF-1)
value: 37.2 Cel (Details: UCUM codeCel = 'Cel')
device: Device: identifier = https://example.org/devices#THERMOMETER-001; status = active; type = 體溫計
Entry 21 - fullUrl = https://example.org/fhir/Device/hah-device
Resource Device:
Generated Narrative: Device hah-device
Profile: 在宅急症-量測設備
identifier:
https://example.org/devices/THERMOMETER-001status: Active
type: 體溫計
patient: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
owner: 在宅急症示範醫療機構 (Healthcare Provider) (https://example.org/organizations#HAH-ORG-1)
Entry 22 - fullUrl = https://example.org/fhir/QuestionnaireResponse/hah-assessment
Resource QuestionnaireResponse:
Generated Narrative: QuestionnaireResponse hah-assessment
Profile: 在宅急症-收案評估回覆
LinkID Text Definition Answer hah-assessment
Questionnaire:在宅急症收案評估 criteria
示範機構收案程序 1.0;本例不作給付判定 home-safety
已確認照護空間及聯絡設備 caregiver-support
照顧者可協助量測並聯繫團隊 decision
在宅急症-收案評估結果代碼: eligible (建議收案) Documentation for this format
Entry 23 - fullUrl = https://example.org/fhir/ClinicalImpression/hah-impression
Resource ClinicalImpression:
Generated Narrative: ClinicalImpression hah-impression
Profile: 在宅急症-臨床評估
status: Completed
subject: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
effective: 2026-09-01 09:30:00+0800
date: 2026-09-01 09:35:00+0800
assessor: 李示範 (https://example.org/practitioners#HAH-STAFF-1)
problem: Condition 呼吸道感染
summary: 已完成本次病情與居家照護需求評估,後續依照護計畫追蹤。
supportingInfo:
Entry 24 - fullUrl = https://example.org/fhir/Procedure/hah-procedure
Resource Procedure:
Generated Narrative: Procedure hah-procedure
Profile: 在宅急症-處置紀錄
status: Completed
code: 照護者衛教
subject: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
performed: 2026-09-01 09:40:00+0800
Performers
Actor 李示範 (https://example.org/practitioners#HAH-STAFF-1) note:
已向照顧者說明量測紀錄與聯繫方式。
Entry 25 - fullUrl = https://example.org/fhir/MedicationRequest/hah-medication-order
Resource MedicationRequest:
Generated Narrative: MedicationRequest hah-medication-order
Profile: 在宅急症-給藥處方
status: Completed
intent: Order
medication: 示範用輸注液
subject: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
authoredOn: 2026-09-01 09:10:00+0800
requester: 李示範 (https://example.org/practitioners#HAH-STAFF-1)
DosageInstructions
Text 本例僅示範輸注期間及速率欄位。
Entry 26 - fullUrl = https://example.org/fhir/MedicationAdministration/hah-infusion
Resource MedicationAdministration:
Generated Narrative: MedicationAdministration hah-infusion
Profile: 在宅急症-給藥與輸注
status: Completed
medication: 示範用輸注液
subject: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
effective: 2026-09-01 09:15:00+0800 --> 2026-09-01 09:45:00+0800
Performers
Actor 李示範 (https://example.org/practitioners#HAH-STAFF-1) Dosages
Route Rate[x] 靜脈 100 mL/h (Details: UCUM codemL/h = 'mL/h')
Entry 27 - fullUrl = https://example.org/fhir/MedicationAdministration/hah-medication-not-done
Resource MedicationAdministration:
Generated Narrative: MedicationAdministration hah-medication-not-done
Profile: 在宅急症-給藥與輸注
status: Not Done
statusReason: 本次給藥經評估取消
medication: 示範用輸注液
subject: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
effective: 2026-09-01 09:50:00+0800
Performers
Actor 李示範 (https://example.org/practitioners#HAH-STAFF-1)
Entry 28 - fullUrl = https://example.org/fhir/AllergyIntolerance/hah-allergy
Resource AllergyIntolerance:
Generated Narrative: AllergyIntolerance hah-allergy
Profile: 在宅急症-過敏資訊
clinicalStatus: Active
verificationStatus: Confirmed
code: 青黴素
patient: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
recordedDate: 2026-09-01 09:00:00+0800
Reactions
Manifestation 皮疹
Entry 29 - fullUrl = https://example.org/fhir/DocumentReference/hah-attachment
Resource DocumentReference:
Generated Narrative: DocumentReference hah-attachment
Profile: 在宅急症-照護附件
status: Current
type: 在宅照護同意文件
subject: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
date: 2026-09-01 08:30:00+0800
author: 李示範 (https://example.org/practitioners#HAH-STAFF-1)
content
Attachments
ContentType Data Title text/plain RXhhbXBsZSBvbmx5合成同意文件 Contexts
Encounter Encounter: status = finished; class = inpatient encounter (ActCode#IMP); type = 在宅急症照護; period = 2026-09-01 09:00:00+0800 --> 2026-09-05 12:00:00+0800
Entry 30 - fullUrl = https://example.org/fhir/Consent/hah-consent
Resource Consent:
Generated Narrative: Consent hah-consent
Profile: 在宅急症-照護同意
Participants
This consent is made under the policy https://example.org/policies/hah-care-consent .
Rule Time Period Rules permit
permit
- Period: 2026-09-01 --> 2026-09-05
Documentation for this format
Entry 31 - fullUrl = https://example.org/fhir/Communication/hah-communication
Resource Communication:
Generated Narrative: Communication hah-communication
Profile: 在宅急症-照會與交班
basedOn: ServiceRequest 專科照會
status: Completed
category: 專科照會
subject: 王測試 Male, DoB: 1945-03-15 ( Provider number: HAH0001)
sent: 2026-09-01 10:00:00+0800
recipient: CareTeam: status = inactive
sender: 李示範 (https://example.org/practitioners#HAH-STAFF-1)
Payloads
Content[x] 已回覆本次照會,請依照護計畫持續追蹤。