Generated Narrative: Composition ltc-composition-referral-example Profile: 長期照護管理中心個案服務初篩表/轉介單文件架構 status: Final type: 長期照顧管理中心個案服務初篩表/轉介單 date: 2024-01-20 09:00:00+0800 author: PractitionerRole Registered nurse title: 陳明慧女士長期照顧服務轉介單
長期照顧管理中心個案服務初篩表/轉介單
Generated Narrative: Patient ltc-patient-referral-chen-ming-hui-example Profile: 轉介單－個案基本資料 陳明慧 Female, DoB: 1945-03-15 ( National Person Identifier (TWN): A123456789 (use: official, )) Active: true Other Id: Provider Number/R2024001 (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: Managing Organization: Organization 新北市私立安康老人長期照顧中心（養護型） 長照機構住民經濟狀況 中產
National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code
Generated Narrative: Condition ltc-condition-disability-referral-example Profile: 長期照顧－身心障礙手冊持有狀態 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 recorder: PractitionerRole Registered nurse
Generated Narrative: Condition ltc-condition-disability-type-limb-referral-example Profile: 長期照顧－身心障礙類型 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 recorder: PractitionerRole Registered nurse
Generated Narrative: Condition ltc-condition-tube-nasogastric-example Profile: 長期照顧－管路裝設狀況 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 recorder: PractitionerRole Registered nurse note: @2024-01-15 持續置放鼻胃管，需定期更換
Generated Narrative: Condition ltc-condition-crush-stage2-example Profile: 長期照顧－壓傷狀況 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 recorder: PractitionerRole Registered nurse 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
部位：薦骨部位，等級：第二期，大小：3x2 cm^2，正在進行傷口護理
Generated Narrative: Condition ltc-condition-residence-not-alone-example Profile: 長期照顧－居住狀況 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
Generated Narrative: Condition ltc-condition-caregiver-family-referral-example Profile: 長期照顧－看護狀況 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 recorder: PractitionerRole Registered nurse 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
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
Generated Narrative: Condition ltc-condition-diabetes-example Profile: 長期照顧－主要疾病 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 recorder: PractitionerRole Registered nurse asserter: PractitionerRole Registered nurse note: @2024-01-15 血糖控制穩定，需持續監測
Generated Narrative: Condition ltc-condition-need-assistance-example Profile: 長期照顧－主要問題及需求 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
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
Generated Narrative: CarePlan ltc-careplan-referral-home-service-example Profile: 轉介單－服務種類 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 author: PractitionerRole Registered nurse 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 Details - Code Status Performer Description * 居家護理 Not Started Organization 新北市私立安康老人長期照顧中心（養護型） 提供居家護理服務，如換藥、傷口照護、健康評估等 activity Details - Code Status Performer Description * 居家吞嚥 Not Started Organization 新北市私立安康老人長期照顧中心（養護型） 提供居家吞嚥訓練與相關照護服務 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
提供居家護理服務，如換藥、傷口照護、健康評估等
提供居家吞嚥訓練與相關照護服務
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
Generated Narrative: QuestionnaireResponse ltc-questionnaire-response-adl-referral-example Profile: ADL 問卷回覆 LinkID Text Definition Answer ltc-questionnaire-response-adl-referral-example Questionnaire:日常生活能力評估量表 #xD; E1 吃飯 5 #xD; E2 洗澡 0 #xD; E3 穿脫衣物 0 #xD; E4 個人修飾 5 #xD; E5 大便控制 10 #xD; E6 小便控制 5 #xD; E7 上廁所 5 #xD; E8 移位 10 #xD; E9 走路 10 #xD; E10 上下樓梯 5 #xD; E11 床椅移位 10 #xD; Documentation for this format
Generated Narrative: QuestionnaireResponse ltc-questionnaire-response-iadl-referral-example Profile: IADL 問卷回覆 LinkID Text Definition Answer ltc-questionnaire-response-iadl-referral-example Questionnaire:LTCQuestionnaireIADL #xD; F1 使用電話 2 #xD; F2 購物 2 #xD; F3 備餐 2 #xD; F4 處理家務 2 #xD; F5 洗衣服 2 #xD; F6 外出 2 #xD; F7 服用藥物 2 #xD; F8 處理財務的能力 2 #xD; Documentation for this format
Generated Narrative: QuestionnaireResponse ltc-questionnaire-response-sof-example Profile: 轉介單－衰弱評估問卷回覆 LinkID Text Definition Answer ltc-questionnaire-response-sof-example Questionnaire:LTCQuestionnaireSOF #xD; sof-1 體重減輕 true #xD; sof-2 下肢功能 false #xD; sof-3 精力降低 true #xD; Documentation for this format
Generated Narrative: QuestionnaireResponse ltc-questionnaire-response-caregiver-referral-example Profile: 轉介單－照顧者問卷回覆 LinkID Text Definition Answer ltc-questionnaire-response-caregiver-referral-example Questionnaire:LTCQuestionnaireCaregiver #xD; caregiver-1 是否有照顧者 是，固定 #xD; Documentation for this format
Generated Narrative: Encounter ltc-encounter-example status: Finished class: ActCode: AMB (ambulatory) subject: 陳明慧 Female, DoB: 1945-03-15 ( National Person Identifier (TWN): A123456789 (use: official, )) period: 2024-01-10 09:00:00+0800 --> 2024-01-10 11:30:00+0800 reasonCode: 糖尿病追蹤檢查 serviceProvider: Organization 新北市私立安康老人長期照顧中心（養護型）
Generated Narrative: Practitioner ltc-practitioner-nurse-example Profile: 長期照顧－照顧服務提供者 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 - Identifier Code * http://example.org/fhir/NamingSystem/nursing-license/護理執照123456 Registered nurse
Generated Narrative: Organization ltc-organization-example Profile: 長期照顧－機構 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） telecom: ph: 02-29412345(Work), fax: 02-29412346(Work) address: 新北市中和區安康路二段123號(work) Contacts - Purpose Name Telecom * Administrative 志明 王 (Official) ph: 02-29412345(Work)
新北市私立安康老人長期照顧中心（養護型）
Generated Narrative: PractitionerRole ltc-practitioner-role-nurse-example Profile: 長期照顧－服務人員角色 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) telecom: ph: 02-29412345(Work), meiling.wang@ltc-center.tw availableTime daysOfWeek: Monday, Tuesday, Wednesday, Thursday, Friday availableStartTime: 08:00:00 availableEndTime: 17:00:00
Generated Narrative: Goal ltc-goal-mobility-improvement-example Profile: 長期照顧－照顧目標 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 - Measure Detail[x] Due[x] * Impaired mobility (finding) 能夠獨立使用助行器行走50公尺 2024-04-15 expressedBy: PractitionerRole Registered nurse 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
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
Generated Narrative: RelatedPerson ltc-related-person-primary-caregiver-referral-example Profile: 長期照顧－關係人 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)