{ "resourceType" : "Bundle", "id" : "hn-careplan-transaction-example", "meta" : { "profile" : ["http://ltc-ig.fhir.tw/StructureDefinition/HNCarePlanTransaction"] }, "type" : "transaction", "entry" : [{ "fullUrl" : "https://example.org/fhir/QuestionnaireResponse/hn-targets-example", "resource" : { "resourceType" : "QuestionnaireResponse", "id" : "hn-targets-example", "meta" : { "profile" : ["http://ltc-ig.fhir.tw/StructureDefinition/HNTargetsResponse"] }, "text" : { "status" : "generated", "div" : "

Generated Narrative: QuestionnaireResponse hn-targets-example

Profile: 居家護理－照護計畫目標表單

\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
LinkIDTextDefinitionAnswer\"doco\"
\".\"\".\" hn-targets-exampleQuestionnaire:居家護理－照護計畫目標
\".\"\".\"\".\" CaseIDA123456789
\".\"\".\"\".\" EndDate2025-12-08
\".\"\".\"\".\" SummaryCreateDate2025-12-08
\".\"\".\"\".\" Summary跌倒問題
\".\"\".\"\".\" SummaryAnswer
\".\"\".\"\".\" TargetStatement降低跌倒風險
\".\"\".\"\".\" TargetCreateDate2025-12-08
\".\"\".\"\".\" EstimatedDate2026-01-08
\".\"\".\"\".\" IsMainTargetfalse
\".\"\".\"\".\" NurseIDB123456789

\"doco\" Documentation for this format
" }, "extension" : [{ "url" : "http://ltc-ig.fhir.tw/StructureDefinition/ExtHNEpisode", "valueReference" : { "reference" : "EpisodeOfCare/hn-episode-example" } }], "questionnaire" : "http://ltc-ig.fhir.tw/Questionnaire/hn-targets", "status" : "in-progress", "subject" : { "reference" : "Patient/hn-patient-example" }, "authored" : "2025-12-08T09:00:00+08:00", "item" : [{ "linkId" : "CaseID", "answer" : [{ "valueString" : "A123456789" }] }, { "linkId" : "EndDate", "answer" : [{ "valueDate" : "2025-12-08" }] }, { "linkId" : "SummaryCreateDate", "answer" : [{ "valueDate" : "2025-12-08" }] }, { "linkId" : "Summary", "answer" : [{ "valueString" : "跌倒問題" }] }, { "linkId" : "SummaryAnswer" }, { "linkId" : "TargetStatement", "answer" : [{ "valueString" : "降低跌倒風險" }] }, { "linkId" : "TargetCreateDate", "answer" : [{ "valueDate" : "2025-12-08" }] }, { "linkId" : "EstimatedDate", "answer" : [{ "valueDate" : "2026-01-08" }] }, { "linkId" : "IsMainTarget", "answer" : [{ "valueBoolean" : false }] }, { "linkId" : "NurseID", "answer" : [{ "valueString" : "B123456789" }] }] }, "request" : { "method" : "PUT", "url" : "QuestionnaireResponse/hn-targets-example" } }, { "fullUrl" : "https://example.org/fhir/QuestionnaireResponse/hn-measures-example", "resource" : { "resourceType" : "QuestionnaireResponse", "id" : "hn-measures-example", "meta" : { "profile" : ["http://ltc-ig.fhir.tw/StructureDefinition/HNMeasuresResponse"] }, "text" : { "status" : "generated", "div" : "

Generated Narrative: QuestionnaireResponse hn-measures-example

Profile: 居家護理－照護計畫措施表單

\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
LinkIDTextDefinitionAnswer\"doco\"
\".\"\".\" hn-measures-exampleQuestionnaire:居家護理－照護計畫措施
\".\"\".\"\".\" CaseIDA123456789
\".\"\".\"\".\" EndDate2025-12-08
\".\"\".\"\".\" SummaryCreateDate2025-12-08
\".\"\".\"\".\" Summary跌倒問題
\".\"\".\"\".\" SummaryAnswer
\".\"\".\"\".\" TargetStatement降低跌倒風險
\".\"\".\"\".\" MeasureCreateDate2025-12-08
\".\"\".\"\".\" MeasureContent每日檢查走道障礙物
\".\"\".\"\".\" NurseIDB123456789
\".\"\".\"\".\" MeasureStopDate2025-12-09
\".\"\".\"\".\" MeasureStopContent改採個別移位協助措施
\".\"\".\"\".\" MeasureStopNurseIDB123456789

\"doco\" Documentation for this format
" }, "extension" : [{ "url" : "http://ltc-ig.fhir.tw/StructureDefinition/ExtHNEpisode", "valueReference" : { "reference" : "EpisodeOfCare/hn-episode-example" } }], "questionnaire" : "http://ltc-ig.fhir.tw/Questionnaire/hn-measures", "status" : "in-progress", "subject" : { "reference" : "Patient/hn-patient-example" }, "authored" : "2025-12-08T09:00:00+08:00", "item" : [{ "linkId" : "CaseID", "answer" : [{ "valueString" : "A123456789" }] }, { "linkId" : "EndDate", "answer" : [{ "valueDate" : "2025-12-08" }] }, { "linkId" : "SummaryCreateDate", "answer" : [{ "valueDate" : "2025-12-08" }] }, { "linkId" : "Summary", "answer" : [{ "valueString" : "跌倒問題" }] }, { "linkId" : "SummaryAnswer" }, { "linkId" : "TargetStatement", "answer" : [{ "valueString" : "降低跌倒風險" }] }, { "linkId" : "MeasureCreateDate", "answer" : [{ "valueDate" : "2025-12-08" }] }, { "linkId" : "MeasureContent", "answer" : [{ "valueString" : "每日檢查走道障礙物" }] }, { "linkId" : "NurseID", "answer" : [{ "valueString" : "B123456789" }] }, { "linkId" : "MeasureStopDate", "answer" : [{ "valueDate" : "2025-12-09" }] }, { "linkId" : "MeasureStopContent", "answer" : [{ "valueString" : "改採個別移位協助措施" }] }, { "linkId" : "MeasureStopNurseID", "answer" : [{ "valueString" : "B123456789" }] }] }, "request" : { "method" : "PUT", "url" : "QuestionnaireResponse/hn-measures-example" } }, { "fullUrl" : "https://example.org/fhir/QuestionnaireResponse/hn-evaluations-example", "resource" : { "resourceType" : "QuestionnaireResponse", "id" : "hn-evaluations-example", "meta" : { "profile" : ["http://ltc-ig.fhir.tw/StructureDefinition/HNEvaluationsResponse"] }, "text" : { "status" : "generated", "div" : "

Generated Narrative: QuestionnaireResponse hn-evaluations-example

Profile: 居家護理－照護計畫評值紀錄表單

\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
LinkIDTextDefinitionAnswer\"doco\"
\".\"\".\" hn-evaluations-exampleQuestionnaire:居家護理－照護計畫評值紀錄
\".\"\".\"\".\" CaseIDA123456789
\".\"\".\"\".\" EndDate2025-12-08
\".\"\".\"\".\" SummaryCreateDate2025-12-08
\".\"\".\"\".\" Summary跌倒問題
\".\"\".\"\".\" SummaryAnswer
\".\"\".\"\".\" TargetStatement降低跌倒風險
\".\"\".\"\".\" EvaluationDate2025-12-08
\".\"\".\"\".\" EvaluationContent評值紀錄範例
\".\"\".\"\".\" NurseIDB123456789

\"doco\" Documentation for this format
" }, "extension" : [{ "url" : "http://ltc-ig.fhir.tw/StructureDefinition/ExtHNEpisode", "valueReference" : { "reference" : "EpisodeOfCare/hn-episode-example" } }], "questionnaire" : "http://ltc-ig.fhir.tw/Questionnaire/hn-evaluations", "status" : "in-progress", "subject" : { "reference" : "Patient/hn-patient-example" }, "authored" : "2025-12-08T09:00:00+08:00", "item" : [{ "linkId" : "CaseID", "answer" : [{ "valueString" : "A123456789" }] }, { "linkId" : "EndDate", "answer" : [{ "valueDate" : "2025-12-08" }] }, { "linkId" : "SummaryCreateDate", "answer" : [{ "valueDate" : "2025-12-08" }] }, { "linkId" : "Summary", "answer" : [{ "valueString" : "跌倒問題" }] }, { "linkId" : "SummaryAnswer" }, { "linkId" : "TargetStatement", "answer" : [{ "valueString" : "降低跌倒風險" }] }, { "linkId" : "EvaluationDate", "answer" : [{ "valueDate" : "2025-12-08" }] }, { "linkId" : "EvaluationContent", "answer" : [{ "valueString" : "評值紀錄範例" }] }, { "linkId" : "NurseID", "answer" : [{ "valueString" : "B123456789" }] }] }, "request" : { "method" : "PUT", "url" : "QuestionnaireResponse/hn-evaluations-example" } }, { "fullUrl" : "https://example.org/fhir/Goal/hn-goal-example", "resource" : { "resourceType" : "Goal", "id" : "hn-goal-example", "meta" : { "profile" : ["http://ltc-ig.fhir.tw/StructureDefinition/HNGoal"] }, "text" : { "status" : "extensions", "div" : "

Generated Narrative: Goal hn-goal-example

Profile: 居家護理－照護目標

居家護理－收案關聯: EpisodeOfCare: extension = ->Response to Questionnaire '->居家護理－個案基本資料' about '->陳明慧 Male, DoB: 1945-03-15 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code)'; identifier = https://example.org/home-nursing/episodes#HN0001-20251208; status = active; period = 2025-12-08 --> (ongoing)

居家護理－來源表單: Response to Questionnaire '->居家護理－照護計畫目標' about '->陳明慧 Male, DoB: 1945-03-15 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code)'

居家護理－主要目標: false

lifecycleStatus: Active

description: 降低跌倒風險

subject: 陳明慧 Male, DoB: 1945-03-15 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code)

start: 2025-12-08

Targets

-Due[x]
*2026-01-08

expressedBy: Practitioner 王美玲

" }, "extension" : [{ "url" : "http://ltc-ig.fhir.tw/StructureDefinition/ExtHNEpisode", "valueReference" : { "reference" : "EpisodeOfCare/hn-episode-example" } }, { "url" : "http://ltc-ig.fhir.tw/StructureDefinition/ExtHNSourceForm", "valueReference" : { "reference" : "QuestionnaireResponse/hn-targets-example" } }, { "url" : "http://ltc-ig.fhir.tw/StructureDefinition/ExtHNMainTarget", "valueBoolean" : false }], "lifecycleStatus" : "active", "description" : { "coding" : [{ "system" : "http://ltc-ig.fhir.tw/CodeSystem/hn-workflow", "code" : "care-goal" }], "text" : "降低跌倒風險" }, "subject" : { "reference" : "Patient/hn-patient-example" }, "startDate" : "2025-12-08", "target" : [{ "dueDate" : "2026-01-08" }], "expressedBy" : { "reference" : "Practitioner/hn-nurse-example" } }, "request" : { "method" : "PUT", "url" : "Goal/hn-goal-example" } }, { "fullUrl" : "https://example.org/fhir/CarePlan/hn-careplan-example", "resource" : { "resourceType" : "CarePlan", "id" : "hn-careplan-example", "meta" : { "profile" : ["http://ltc-ig.fhir.tw/StructureDefinition/HNCarePlan"] }, "text" : { "status" : "additional", "div" : "

陳明慧的居家護理照護計畫：降低跌倒風險。原措施為每日檢查走道障礙物，已停止並改採個別移位協助措施。照護者應依護理人員指導執行。

" }, "extension" : [{ "url" : "http://ltc-ig.fhir.tw/StructureDefinition/ExtHNEpisode", "valueReference" : { "reference" : "EpisodeOfCare/hn-episode-example" } }, { "url" : "http://ltc-ig.fhir.tw/StructureDefinition/ExtHNSourceForm", "valueReference" : { "reference" : "QuestionnaireResponse/hn-targets-example" } }, { "url" : "http://ltc-ig.fhir.tw/StructureDefinition/ExtHNSourceForm", "valueReference" : { "reference" : "QuestionnaireResponse/hn-measures-example" } }], "status" : "active", "intent" : "plan", "category" : [{ "coding" : [{ "system" : "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/careplan-category-tw", "code" : "assess-plan" }] }], "subject" : { "reference" : "Patient/hn-patient-example" }, "period" : { "start" : "2025-12-08" }, "author" : { "reference" : "Practitioner/hn-nurse-example" }, "supportingInfo" : [{ "reference" : "QuestionnaireResponse/hn-casesummary-example" }], "goal" : [{ "reference" : "Goal/hn-goal-example" }], "activity" : [{ "extension" : [{ "extension" : [{ "url" : "date", "valueDate" : "2025-12-09" }, { "url" : "reason", "valueString" : "改採個別移位協助措施" }, { "url" : "nurse", "valueReference" : { "reference" : "Practitioner/hn-nurse-example" } }], "url" : "http://ltc-ig.fhir.tw/StructureDefinition/ExtHNMeasureStop" }], "outcomeReference" : [{ "reference" : "QuestionnaireResponse/hn-evaluations-example" }], "detail" : { "goal" : [{ "reference" : "Goal/hn-goal-example" }], "status" : "stopped", "scheduledPeriod" : { "start" : "2025-12-08" }, "description" : "每日檢查走道障礙物" } }] }, "request" : { "method" : "PUT", "url" : "CarePlan/hn-careplan-example" } }] }