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

Questionnaire: 居家護理－照護紀錄問卷

Official URL: http://ltc-ig.fhir.tw/Questionnaire/hn-carerecord Version: 1.1.0
Draft as of 2025-12-08 Computable Name: HNCareRecordQuestionnaire

V5.0.16 照護紀錄的問題結構與輸入型態。

LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. HNCareRecordQuestionnaireV5.0.16 照護紀錄的問題結構與輸入型態。Questionnairehttp://ltc-ig.fhir.tw/Questionnaire/hn-carerecord#1.1.0
... CaseID個案身分證字號1..1stringMax Length: 10
Value Set:
... EndDate收案日期1..1dateValue Set:
... Date紀錄日期1..1dateValue Set:
... NurseID護理人員身分證字號1..1stringMax Length: 10
Value Set:
... Time照護開始時間1..1timeValue Set:
... Time2照護結束時間1..1timeValue Set:
... RecordSource紀錄來源1..1groupValue Set:
.... RecordSource.Value選項1..1choiceValue Set: 居家護理－紀錄來源選項
.... RecordSource.Other補充說明0..1stringMax Length: 100
Value Set:
... Height身高（公分）0..1decimalValue Set:
... Weight體重（公斤）0..1decimalValue Set:
... BMI身體質量指數0..1decimalValue Set:
... ArmW臂中圍（公分）0..1decimalValue Set:
... LegW小腿圍（公分）0..1decimalValue Set:
... Live居住所1..1groupValue Set:
.... Live.Value選項1..1choiceValue Set: 居家護理－居住所選項
.... Live.Other補充說明0..1stringMax Length: 100
Value Set:
... LiveArea居住區域1..1groupValue Set:
.... LiveArea.City縣市1..1stringMax Length: 100
Value Set:
.... LiveArea.Area鄉鎮市區1..1stringMax Length: 100
Value Set:
... UseResources使用資源0..1groupValue Set:
.... UseResources.Values選項0..*choiceValue Set: 居家護理－使用資源多選選項
.... UseResources.Other補充說明0..1stringMax Length: 100
Value Set:
... ServiceItems服務項目0..1groupValue Set:
.... ServiceItems.Values選項0..*choiceValue Set: 居家護理－服務項目多選選項
.... ServiceItems.Other補充說明0..1stringMax Length: 100
Value Set:
... IsUnplanned是否非計畫性再住院1..1choiceValue Set: 居家護理－是否選項
... Unplanned非計畫性再住院0..1groupValue Set:
.... Unplanned.Date發生日期1..1dateValue Set:
.... Unplanned.Time發生時段1..1choiceValue Set: 居家護理－發生時段選項
.... Unplanned.Statement發生原因1..1stringMax Length: 2100
Value Set:
... IsEmergency是否使用急診1..1choiceValue Set: 居家護理－是否選項
... Emergency使用急診0..1groupValue Set:
.... Emergency.Date發生日期1..1dateValue Set:
.... Emergency.Time發生時段1..1choiceValue Set: 居家護理－發生時段選項
.... Emergency.Statement發生原因1..1stringMax Length: 2100
Value Set:
... IsSkinDamages是否皮膚損傷1..1choiceValue Set: 居家護理－是否選項
... SkinDamages皮膚損傷0..*groupValue Set:
.... SkinDamages.Date發生日期1..1dateValue Set:
.... SkinDamages.Time發生時段1..1choiceValue Set: 居家護理－發生時段選項
.... SkinDamages.Kind損傷類型0..1groupValue Set:
..... SkinDamages.Kind.Value選項1..1choiceValue Set: 居家護理－損傷類型選項
..... SkinDamages.Kind.Other補充說明0..1stringMax Length: 100
Value Set:
.... SkinDamages.Statement發生原因1..1stringMax Length: 2100
Value Set:
... IsEmergencyEvents是否緊急事件1..1choiceValue Set: 居家護理－是否選項
... EmergencyEvents緊急事件0..*groupValue Set:
.... EmergencyEvents.EmergencyType事件類型1..1groupValue Set:
..... EmergencyEvents.EmergencyType.Value選項1..1choiceValue Set: 居家護理－事件類型選項
..... EmergencyEvents.EmergencyType.Other補充說明0..1stringMax Length: 100
Value Set:
.... EmergencyEvents.Date發生日期1..1dateValue Set:
.... EmergencyEvents.Time發生時段1..1choiceValue Set: 居家護理－發生時段選項
.... EmergencyEvents.Reason發生原因1..1stringMax Length: 100
Value Set:
.... EmergencyEvents.Description事件描述1..1stringMax Length: 200
Value Set:
.... EmergencyEvents.Process通報及處理過程1..1stringMax Length: 200
Value Set:
.... EmergencyEvents.Report檢討紀錄1..1stringMax Length: 200
Value Set:
.... EmergencyEvents.CreateID照護人員身分證字號1..1stringMax Length: 10
Value Set:
... VitalSign生命徵象0..1groupValue Set:
.... VitalSign.Date量測日期1..1dateValue Set:
.... VitalSign.Time量測時間1..1timeValue Set:
.... VitalSign.Temperature體溫1..1decimalValue Set:
.... VitalSign.Pulse脈搏1..1integerValue Set:
.... VitalSign.Respiration呼吸1..1integerValue Set:
.... VitalSign.BloodPressure1收縮壓1..1integerValue Set:
.... VitalSign.BloodPressure2舒張壓1..1integerValue Set:
.... VitalSign.BloodGlucose血糖0..1integerValue Set:
.... VitalSign.BloodOxygen血氧0..1integerValue Set:
... WoundRecords傷口紀錄0..*groupValue Set:
.... WoundRecords.Part傷口部位1..1stringMax Length: 10
Value Set:
.... WoundRecords.Length傷口長度0..1decimalValue Set:
.... WoundRecords.Width傷口寬度0..1decimalValue Set:
.... WoundRecords.Depth傷口深度0..1decimalValue Set:
.... WoundRecords.Category傷口分類1..1choiceValue Set: 居家護理－傷口分類選項
.... WoundRecords.Level傷口等級0..1choiceValue Set: 居家護理－傷口等級選項
.... WoundRecords.Statement傷口說明0..1stringMax Length: 100
Value Set:
... FJMEvaluation足部護理評估狀態0..1choiceValue Set: 居家護理－足部護理評估狀態選項
... FJM足部護理0..*groupValue Set:
.... FJM.Item項目分類1..1choiceValue Set: 居家護理－項目分類選項
.... FJM.Question評估項目1..1choiceValue Set: 居家護理－評估項目選項
.... FJM.Answers答案1..1groupValue Set:
..... FJM.Answers.Values選項0..*stringMax Length: 100
Value Set:
..... FJM.Answers.Other補充說明0..1stringMax Length: 100
Value Set:
..... FJM.Answers.FJMList操作項目紀錄0..*groupValue Set:
...... FJM.Answers.FJMList.SubQuestion操作項目與流程1..1choiceValue Set: 居家護理－操作項目與流程選項
...... FJM.Answers.FJMList.SubAnswers有反應物1..1choiceValue Set: 居家護理－是否選項
...... FJM.Answers.FJMList.SubStatement觀察紀錄1..1stringMax Length: 100
Value Set:
..... FJM.Answers.FJMVas疼痛量尺0..1groupValue Set:
...... FJM.Answers.FJMVas.Part疼痛部位1..1stringMax Length: 100
Value Set:
...... FJM.Answers.FJMVas.Point疼痛程度1..1integerValue Set:
.... FJM.Statement主訴敘述0..1stringMax Length: 1000
Value Set:
... Statement照護紀錄1..1stringMax Length: 1000
Value Set:
... IsTemporary是否暫存0..1choiceValue Set: 居家護理－是否選項

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