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

Example Bundle: 轉介單文件打包範例

Document Subject

陳明慧 Female, DoB: 1945-03-15 ( Provider Number: R2024001 (use: official, ))

Active:true
Other Id:National Person Identifier (TWN)/A123456789 (use: official, )
Alt. Name:Chen Ming Hui(Official)
Contact Detail
  • ph: 0912345678(Mobile)
  • 新北市中和區安康路二段123號3樓301室(home)
  • 台北市大安區和平東路二段76號2樓(billing)
Next-of-Kin:
  • 陳志強
  • ph: 0987654321(Mobile)
Links:
長照機構住民經濟狀況中產

Document Content

個案基本資料

身心障礙手冊

管路

壓傷

居住狀況

看護

疾病狀況

案主(家)主要問題及需求

欲申請服務之種類

ADL 失能項目評估

IADL 失能項目評估

長者衰弱評估

照顧者評估

出入院情形

填表者/轉介者資訊及簽名欄

填表單位資訊

關係人

Additional Resources Included in Document

Entry 2 - fullUrl = http://ltc-ig.fhir.tw/Patient/ltc-patient-referral-chen-ming-hui-example

Resource Patient:

陳明慧 Female, DoB: 1945-03-15 ( Provider Number: R2024001 (use: official, ))

Active:true
Other Id:National Person Identifier (TWN)/A123456789 (use: official, )
Alt. Name:Chen Ming Hui(Official)
Contact Detail
  • ph: 0912345678(Mobile)
  • 新北市中和區安康路二段123號3樓301室(home)
  • 台北市大安區和平東路二段76號2樓(billing)
Next-of-Kin:
  • 陳志強
  • ph: 0987654321(Mobile)
Links:
長照機構住民經濟狀況中產

Entry 3 - fullUrl = http://ltc-ig.fhir.tw/Condition/ltc-condition-disability-referral-example

Resource Condition:

clinicalStatus: Active

verificationStatus: Confirmed

category: Problem List Item

code: 有身心障礙手冊

subject: 陳明慧 Female, DoB: 1945-03-15 ( National Person Identifier (TWN): A123456789 (use: official, ))

onset: 2015-08-20

Entry 4 - fullUrl = http://ltc-ig.fhir.tw/Condition/ltc-condition-disability-type-limb-referral-example

Resource Condition:

clinicalStatus: Active

verificationStatus: Confirmed

category: Problem List Item

code: 第七類

subject: 陳明慧 Female, DoB: 1945-03-15 ( National Person Identifier (TWN): A123456789 (use: official, ))

onset: 2015-08-20

Entry 5 - fullUrl = http://ltc-ig.fhir.tw/Condition/ltc-condition-tube-nasogastric-example

Resource Condition:

clinicalStatus: Active

verificationStatus: Confirmed

category: Problem List Item

code: 鼻胃管

subject: 陳明慧 Female, DoB: 1945-03-15 ( National Person Identifier (TWN): A123456789 (use: official, ))

onset: 2024-01-01

note: @2024-01-15

持續置放鼻胃管，需定期更換

Entry 6 - fullUrl = http://ltc-ig.fhir.tw/Condition/ltc-condition-crush-stage2-example

Resource Condition:

clinicalStatus: Active

verificationStatus: Confirmed

category: Problem List Item

code: 壓傷

bodySite: Bone structure of sacrum

subject: 陳明慧 Female, DoB: 1945-03-15 ( National Person Identifier (TWN): A123456789 (use: official, ))

onset: 2024-01-10

note: @2024-01-15

部位：薦骨部位，等級：第二期，大小：3x2 cm^2，正在進行傷口護理

Entry 7 - fullUrl = http://ltc-ig.fhir.tw/Condition/ltc-condition-residence-not-alone-example

Resource Condition:

clinicalStatus: Active

verificationStatus: Confirmed

category: Problem List Item

code: 非獨居

subject: 陳明慧 Female, DoB: 1945-03-15 ( National Person Identifier (TWN): A123456789 (use: official, ))

note: @2024-01-15

與配偶同住

Entry 8 - fullUrl = http://ltc-ig.fhir.tw/Condition/ltc-condition-caregiver-family-referral-example

Resource Condition:

clinicalStatus: Active

verificationStatus: Confirmed

category: Problem List Item

code: 有看護

subject: 陳明慧 Female, DoB: 1945-03-15 ( National Person Identifier (TWN): A123456789 (use: official, ))

onset: 2024-01-01

note: @2024-01-15

主要照顧者為兒子，本國籍，每日照顧時間約8小時，無外籍看護

Entry 9 - fullUrl = http://ltc-ig.fhir.tw/Condition/ltc-condition-diabetes-example

Resource Condition:

clinicalStatus: Active

verificationStatus: Confirmed

category: Encounter Diagnosis

code: 第2型糖尿病

subject: 陳明慧 Female, DoB: 1945-03-15 ( National Person Identifier (TWN): A123456789 (use: official, ))

onset: 2020-05-15

note: @2024-01-15

血糖控制穩定，需持續監測

Entry 10 - fullUrl = http://ltc-ig.fhir.tw/Condition/ltc-condition-need-assistance-example

Resource Condition:

clinicalStatus: Active

verificationStatus: Confirmed

category: Problem List Item

severity: Severe

code: 需要協助刮鬍

subject: 陳明慧 Female, DoB: 1945-03-15 ( National Person Identifier (TWN): A123456789 (use: official, ))

onset: 2024-01-15

recordedDate: 2024-09-15

note:

個案由於身體功能退化，在日常生活活動上需要他人協助，包括洗澡、穿衣、進食等基本活動

Entry 11 - fullUrl = http://ltc-ig.fhir.tw/CarePlan/ltc-careplan-referral-home-service-example

Resource CarePlan:

status: Active

intent: Proposal

category: Assessment and Plan of Treatment

subject: 陳明慧 Female, DoB: 1945-03-15 ( National Person Identifier (TWN): A123456789 (use: official, ))

period: 2024-02-01 --> 2024-08-01

goal: Goal: lifecycleStatus = active; description = Advancing mobility; start[x] = 2024-01-15; note = 住民目前需要部分協助才能行走，期望透過復健訓練達到獨立行走的目標

activity

activity

note: @2024-01-20

個案需要居家照顧及復健服務，由照管中心評估後安排服務提供單位

Entry 12 - fullUrl = http://ltc-ig.fhir.tw/QuestionnaireResponse/ltc-questionnaire-response-adl-referral-example

Resource QuestionnaireResponse:

LinkIDTextDefinitionAnswerdoco
.. ltc-questionnaire-response-adl-referral-exampleQuestionnaire:日常生活能力評估量表
... E1吃飯5
... E2洗澡0
... E3穿脫衣物0
... E4個人修飾5
... E5大便控制10
... E6小便控制5
... E7上廁所5
... E8移位10
... E9走路10
... E10上下樓梯5
... E11床椅移位10

doco Documentation for this format

Entry 13 - fullUrl = http://ltc-ig.fhir.tw/QuestionnaireResponse/ltc-questionnaire-response-iadl-referral-example

Resource QuestionnaireResponse:

LinkIDTextDefinitionAnswerdoco
.. ltc-questionnaire-response-iadl-referral-exampleQuestionnaire:LTCQuestionnaireIADL
... F1使用電話2
... F2購物2
... F3備餐2
... F4處理家務2
... F5洗衣服2
... F6外出2
... F7服用藥物2
... F8處理財務的能力2

doco Documentation for this format

Entry 14 - fullUrl = http://ltc-ig.fhir.tw/QuestionnaireResponse/ltc-questionnaire-response-sof-example

Resource QuestionnaireResponse:

LinkIDTextDefinitionAnswerdoco
.. ltc-questionnaire-response-sof-exampleQuestionnaire:LTCQuestionnaireSOF
... sof-1體重減輕true
... sof-2下肢功能false
... sof-3精力降低true

doco Documentation for this format

Entry 15 - fullUrl = http://ltc-ig.fhir.tw/QuestionnaireResponse/ltc-questionnaire-response-caregiver-referral-example

Resource QuestionnaireResponse:

LinkIDTextDefinitionAnswerdoco
.. ltc-questionnaire-response-caregiver-referral-exampleQuestionnaire:LTCQuestionnaireCaregiver
... caregiver-1是否有照顧者是，固定

doco Documentation for this format

Entry 16 - fullUrl = http://ltc-ig.fhir.tw/Encounter/ltc-encounter-example

Resource Encounter:

status: completed

class: ambulatory

subject: 陳明慧 Female, DoB: 1945-03-15 ( National Person Identifier (TWN): A123456789 (use: official, ))

serviceProvider: Organization 新北市私立安康老人長期照顧中心（養護型）

Entry 17 - fullUrl = http://ltc-ig.fhir.tw/Practitioner/ltc-practitioner-nurse-example

Resource Practitioner:

identifier: Provider Number/N123456789 (use: official, )

active: true

name: 王美玲(Official)

telecom: ph: 02-29412345(Work), meiling.wang@ltc-center.tw

gender: Female

Qualifications

-IdentifierCode
*http://example.org/fhir/NamingSystem/nursing-license/護理執照123456Registered nurse

Entry 18 - fullUrl = http://ltc-ig.fhir.tw/Organization/ltc-organization-example

Resource Organization:

identifier: Provider Number/0131060029 (use: usual, )

active: true

type: Healthcare Provider

name: 新北市私立安康老人長期照顧中心（養護型）

contact

telecom: ph: 02-29412345(Work), fax: 02-29412346(Work)

address: 新北市中和區安康路二段123號(work)

contact

purpose: Administrative

name: 志明 王 (Official)

telecom: ph: 02-29412345(Work)

Entry 19 - fullUrl = http://ltc-ig.fhir.tw/PractitionerRole/ltc-practitioner-role-nurse-example

Resource PractitionerRole:

active: true

practitioner: Practitioner 王美玲(official)

organization: Organization 新北市私立安康老人長期照顧中心（養護型）

code: Registered nurse

specialty: General surgery (qualifier value)

Entry 20 - fullUrl = http://ltc-ig.fhir.tw/Goal/ltc-goal-mobility-improvement-example

Resource Goal:

lifecycleStatus: Active

description: 改善住民行動能力

subject: 陳明慧 Female, DoB: 1945-03-15 ( National Person Identifier (TWN): A123456789 (use: official, ))

start: 2024-01-15

Targets

-MeasureDetail[x]Due[x]
*Impaired mobility (finding)能夠獨立使用助行器行走50公尺2024-04-15

note: @2024-01-15

住民目前需要部分協助才能行走，期望透過復健訓練達到獨立行走的目標

Entry 21 - fullUrl = http://ltc-ig.fhir.tw/RelatedPerson/ltc-related-person-primary-caregiver-referral-example

Resource RelatedPerson:

是否為主要照顧者: true

active: true

patient: 陳明慧 Female, DoB: 1945-03-15 ( National Person Identifier (TWN): A123456789 (use: official, ))

relationship: child

name: 陳志強

telecom: ph: 0987654321(Mobile)

gender: Male

address: 台北市大安區仁愛路三段55號8樓(home)