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 CarePlan: 轉介單居家服務計畫範例

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