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。
Profile: 長期照顧－問卷
| LinkID | Text | Cardinality | Type | Description & Constraints |
|---|---|---|---|---|
  HNCareRecordQuestionnaire | V5.0.16 照護紀錄的問題結構與輸入型態。 | Questionnaire | http://ltc-ig.fhir.tw/Questionnaire/hn-carerecord#1.1.0 | |
  CaseID | 個案身分證字號 | 1..1 | string | Max Length: 10 Value Set: |
 EndDate | 收案日期 | 1..1 | date | Value Set: |
| Date | 紀錄日期 | 1..1 | date | Value Set: |
| NurseID | 護理人員身分證字號 | 1..1 | string | Max Length: 10 Value Set: |
 Time | 照護開始時間 | 1..1 | time | Value Set: |
| Time2 | 照護結束時間 | 1..1 | time | Value Set: |
  RecordSource | 紀錄來源 | 1..1 | group | Value Set: |
  RecordSource.Value | 選項 | 1..1 | choice | Value Set: 居家護理－紀錄來源選項 |
 RecordSource.Other | 補充說明 | 0..1 | string | Max Length: 100 Value Set: |
 Height | 身高（公分） | 0..1 | decimal | Value Set: |
| Weight | 體重（公斤） | 0..1 | decimal | Value Set: |
| BMI | 身體質量指數 | 0..1 | decimal | Value Set: |
| ArmW | 臂中圍（公分） | 0..1 | decimal | Value Set: |
| LegW | 小腿圍（公分） | 0..1 | decimal | Value Set: |
| Live | 居住所 | 1..1 | group | Value Set: |
| Live.Value | 選項 | 1..1 | choice | Value Set: 居家護理－居住所選項 |
| Live.Other | 補充說明 | 0..1 | string | Max Length: 100 Value Set: |
| LiveArea | 居住區域 | 1..1 | group | Value Set: |
| LiveArea.City | 縣市 | 1..1 | string | Max Length: 100 Value Set: |
| LiveArea.Area | 鄉鎮市區 | 1..1 | string | Max Length: 100 Value Set: |
| UseResources | 使用資源 | 0..1 | group | Value Set: |
| UseResources.Values | 選項 | 0..* | choice | Value Set: 居家護理－使用資源多選選項 |
| UseResources.Other | 補充說明 | 0..1 | string | Max Length: 100 Value Set: |
| ServiceItems | 服務項目 | 0..1 | group | Value Set: |
| ServiceItems.Values | 選項 | 0..* | choice | Value Set: 居家護理－服務項目多選選項 |
| ServiceItems.Other | 補充說明 | 0..1 | string | Max Length: 100 Value Set: |
| IsUnplanned | 是否非計畫性再住院 | 1..1 | choice | Value Set: 居家護理－是否選項 |
| Unplanned | 非計畫性再住院 | 0..1 | group | Value Set: |
| Unplanned.Date | 發生日期 | 1..1 | date | Value Set: |
| Unplanned.Time | 發生時段 | 1..1 | choice | Value Set: 居家護理－發生時段選項 |
| Unplanned.Statement | 發生原因 | 1..1 | string | Max Length: 2100 Value Set: |
| IsEmergency | 是否使用急診 | 1..1 | choice | Value Set: 居家護理－是否選項 |
| Emergency | 使用急診 | 0..1 | group | Value Set: |
| Emergency.Date | 發生日期 | 1..1 | date | Value Set: |
| Emergency.Time | 發生時段 | 1..1 | choice | Value Set: 居家護理－發生時段選項 |
| Emergency.Statement | 發生原因 | 1..1 | string | Max Length: 2100 Value Set: |
| IsSkinDamages | 是否皮膚損傷 | 1..1 | choice | Value Set: 居家護理－是否選項 |
| SkinDamages | 皮膚損傷 | 0..* | group | Value Set: |
| SkinDamages.Date | 發生日期 | 1..1 | date | Value Set: |
| SkinDamages.Time | 發生時段 | 1..1 | choice | Value Set: 居家護理－發生時段選項 |
| SkinDamages.Kind | 損傷類型 | 0..1 | group | Value Set: |
| SkinDamages.Kind.Value | 選項 | 1..1 | choice | Value Set: 居家護理－損傷類型選項 |
| SkinDamages.Kind.Other | 補充說明 | 0..1 | string | Max Length: 100 Value Set: |
| SkinDamages.Statement | 發生原因 | 1..1 | string | Max Length: 2100 Value Set: |
| IsEmergencyEvents | 是否緊急事件 | 1..1 | choice | Value Set: 居家護理－是否選項 |
| EmergencyEvents | 緊急事件 | 0..* | group | Value Set: |
| EmergencyEvents.EmergencyType | 事件類型 | 1..1 | group | Value Set: |
| EmergencyEvents.EmergencyType.Value | 選項 | 1..1 | choice | Value Set: 居家護理－事件類型選項 |
| EmergencyEvents.EmergencyType.Other | 補充說明 | 0..1 | string | Max Length: 100 Value Set: |
| EmergencyEvents.Date | 發生日期 | 1..1 | date | Value Set: |
| EmergencyEvents.Time | 發生時段 | 1..1 | choice | Value Set: 居家護理－發生時段選項 |
| EmergencyEvents.Reason | 發生原因 | 1..1 | string | Max Length: 100 Value Set: |
| EmergencyEvents.Description | 事件描述 | 1..1 | string | Max Length: 200 Value Set: |
| EmergencyEvents.Process | 通報及處理過程 | 1..1 | string | Max Length: 200 Value Set: |
| EmergencyEvents.Report | 檢討紀錄 | 1..1 | string | Max Length: 200 Value Set: |
| EmergencyEvents.CreateID | 照護人員身分證字號 | 1..1 | string | Max Length: 10 Value Set: |
| VitalSign | 生命徵象 | 0..1 | group | Value Set: |
| VitalSign.Date | 量測日期 | 1..1 | date | Value Set: |
| VitalSign.Time | 量測時間 | 1..1 | time | Value Set: |
| VitalSign.Temperature | 體溫 | 1..1 | decimal | Value Set: |
 VitalSign.Pulse | 脈搏 | 1..1 | integer | Value Set: |
| VitalSign.Respiration | 呼吸 | 1..1 | integer | Value Set: |
| VitalSign.BloodPressure1 | 收縮壓 | 1..1 | integer | Value Set: |
| VitalSign.BloodPressure2 | 舒張壓 | 1..1 | integer | Value Set: |
| VitalSign.BloodGlucose | 血糖 | 0..1 | integer | Value Set: |
| VitalSign.BloodOxygen | 血氧 | 0..1 | integer | Value Set: |
| WoundRecords | 傷口紀錄 | 0..* | group | Value Set: |
| WoundRecords.Part | 傷口部位 | 1..1 | string | Max Length: 10 Value Set: |
| WoundRecords.Length | 傷口長度 | 0..1 | decimal | Value Set: |
| WoundRecords.Width | 傷口寬度 | 0..1 | decimal | Value Set: |
| WoundRecords.Depth | 傷口深度 | 0..1 | decimal | Value Set: |
| WoundRecords.Category | 傷口分類 | 1..1 | choice | Value Set: 居家護理－傷口分類選項 |
| WoundRecords.Level | 傷口等級 | 0..1 | choice | Value Set: 居家護理－傷口等級選項 |
| WoundRecords.Statement | 傷口說明 | 0..1 | string | Max Length: 100 Value Set: |
| FJMEvaluation | 足部護理評估狀態 | 0..1 | choice | Value Set: 居家護理－足部護理評估狀態選項 |
| FJM | 足部護理 | 0..* | group | Value Set: |
| FJM.Item | 項目分類 | 1..1 | choice | Value Set: 居家護理－項目分類選項 |
| FJM.Question | 評估項目 | 1..1 | choice | Value Set: 居家護理－評估項目選項 |
| FJM.Answers | 答案 | 1..1 | group | Value Set: |
| FJM.Answers.Values | 選項 | 0..* | string | Max Length: 100 Value Set: |
| FJM.Answers.Other | 補充說明 | 0..1 | string | Max Length: 100 Value Set: |
| FJM.Answers.FJMList | 操作項目紀錄 | 0..* | group | Value Set: |
| FJM.Answers.FJMList.SubQuestion | 操作項目與流程 | 1..1 | choice | Value Set: 居家護理－操作項目與流程選項 |
| FJM.Answers.FJMList.SubAnswers | 有反應物 | 1..1 | choice | Value Set: 居家護理－是否選項 |
| FJM.Answers.FJMList.SubStatement | 觀察紀錄 | 1..1 | string | Max Length: 100 Value Set: |
 FJM.Answers.FJMVas | 疼痛量尺 | 0..1 | group | Value Set: |
 FJM.Answers.FJMVas.Part | 疼痛部位 | 1..1 | string | Max Length: 100 Value Set: |
| FJM.Answers.FJMVas.Point | 疼痛程度 | 1..1 | integer | Value Set: |
| FJM.Statement | 主訴敘述 | 0..1 | string | Max Length: 1000 Value Set: |
| Statement | 照護紀錄 | 1..1 | string | Max Length: 1000 Value Set: |
| IsTemporary | 是否暫存 | 0..1 | choice | Value Set: 居家護理－是否選項 |
| Documentation for this format | ||||