臺灣榮總腦中風實作指引(TW VGH Stroke IG)
0.1.0 - ci-build

臺灣榮總腦中風實作指引(TW VGH Stroke IG), published by 高雄榮民總醫院 (VGHKS). This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/SitatechCo/TWVGHStroke_IG_Build/ and changes regularly. See the Directory of published versions

Example Bundle: 腦中風個管系統個案資料包範例

Bundle stroke-bundle-ncva-example of type collection


Entry 1 - fullUrl = http://vgh-stroke-ig.fhir.tw/Patient/stroke-patient-example

Resource Patient:

Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))


Active:true
Links:

Entry 2 - fullUrl = http://vgh-stroke-ig.fhir.tw/Organization/stroke-organization-vghks

Resource Organization:

高雄榮民總醫院 (Healthcare Provider) (Organization identifier: 1A0 (use: usual))


Active:true
Type:Healthcare Provider

Entry 3 - fullUrl = http://vgh-stroke-ig.fhir.tw/Encounter/stroke-encounter-er-example

Resource Encounter:

status: completed

class: emergency

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

serviceProvider: 高雄榮民總醫院 (Healthcare Provider) (Organization identifier: 1A0 (use: usual))


Entry 4 - fullUrl = http://vgh-stroke-ig.fhir.tw/Encounter/stroke-encounter-example

Resource Encounter:

status: completed

class: inpatient encounter

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

serviceProvider: 高雄榮民總醫院 (Healthcare Provider) (Organization identifier: 1A0 (use: usual))


Entry 5 - fullUrl = http://vgh-stroke-ig.fhir.tw/QuestionnaireResponse/stroke-registry-response-ncva-example

Resource QuestionnaireResponse:

LinkIDTextDefinitionAnswerdoco
stroke-registry-response-ncva-exampleQuestionnaire:腦中風登錄表單
stroke-registry-response-ncva-example / inpatientTreatment.tre09住院期間簽署 DNRfalse
stroke-registry-response-ncva-example / raw.ncva個管系統原始值
stroke-registry-response-ncva-example / raw.ncva / raw.ncva.hisnummark病歷號EX00000001
stroke-registry-response-ncva-example / raw.ncva / raw.ncva.cmseqno個管流水序號CM-EXAMPLE-0001

doco Documentation for this format

Entry 6 - fullUrl = http://vgh-stroke-ig.fhir.tw/Provenance/stroke-provenance-example

Resource Provenance:

Provenance for:

Summary

Occurrence2025-01-16 14:30:00+0800
Recorded2025-02-01 10:00:00+0800

Agents

Typewho
Enterer李小華
Author高雄榮民總醫院 (Healthcare Provider) (Organization identifier: 1A0 (use: usual))

Entities

RoleWhat
Source腦中風登錄來源紀錄(範例) (Identifier: http://www.vghks.gov.tw/stroke-registry-record/EX-REC-0001)

Entry 7 - fullUrl = http://vgh-stroke-ig.fhir.tw/Condition/stroke-condition-example

Resource Condition:

clinicalStatus: Active

category: Encounter Diagnosis

code: 腦梗塞

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28


Entry 8 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-arrival-mode-example

Resource Observation:

腦中風-評估時點: admission

status: Final

category: Survey

code: 到院方式

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15

value: 緊急醫療救護(EMS)


Entry 9 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-patient-age-example

Resource Observation:

腦中風-評估時點: admission

status: Final

category: Survey

code: 病人年齡

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15

value: 72 歲 (Details: UCUM codea = 'a')


Entry 10 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-education-level-example

Resource Observation:

status: Final

category: Survey

code: 教育程度

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15

value: 高中職


Entry 11 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-onset-time-only-example

Resource Observation:

status: Final

category: Survey

code: 中風發病時間

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

value: 腦中風-來源事件時間: 06:40:00


Entry 12 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-hypertension-history-example

Resource Observation:

腦中風-評估時點: admission

status: Final

category: Survey

code: 高血壓病史

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15

value: true


Entry 13 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-diabetes-history-unknown-example

Resource Observation:

status: Final

category: Survey

code: 糖尿病病史

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15

dataAbsentReason: Unknown


Entry 14 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-family-history-stroke-example

Resource Observation:

status: Final

category: Survey

code: 中風或短暫性腦缺血家族史

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15

value: false


Entry 15 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-cigarettes-per-day-example

Resource Observation:

status: Final

category: Survey

code: 每日吸菸量

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15

value: 20 {cigarette}/d (Details: UCUM code{cigarette}/d = '{cigarette}/d')


Entry 16 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-toast-classification-example

Resource Observation:

status: Final

category: Survey

code: TOAST 分類

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15

value: 心因性栓塞


Entry 17 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-ecg-atrial-fibrillation-example

Resource Observation:

status: Final

category: Survey

code: 心電圖心房顫動

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15

value: true


Entry 18 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-icu-admission-example

Resource Observation:

status: Final

category: Survey

code: 入住加護病房

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15

value: true


Entry 19 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-neurologic-deterioration-example

Resource Observation:

status: Final

category: Survey

code: 中風惡化(NIHSS 增加至少 2 分)

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

value: false


Entry 20 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-nihss-admission-example

Resource Observation:

腦中風-評估時點: admission

腦中風-評估序號: 1

status: Final

category: Survey

code: Total score [NIH Stroke Scale]

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15 10:30:00+0800

value: 12

component

code: Level of consciousness [NIH Stroke Scale]

value: 0

component

code: LOC questions [NIH Stroke Scale]

value: 1

component

code: LOC commands [NIH Stroke Scale]

value: 0

component

code: Best gaze [NIH Stroke Scale]

value: 1

component

code: Visual [NIH Stroke Scale]

value: 0

component

code: Facial palsy [NIH Stroke Scale]

value: 2

component

code: Motor arm Left arm [NIH Stroke Scale]

value: 0

component

code: Motor arm Right arm [NIH Stroke Scale]

value: 3

component

code: Motor leg Leg - left [NIH Stroke Scale]

value: 0

component

code: Motor leg Leg - right [NIH Stroke Scale]

value: 2

component

code: Limb ataxia [NIH Stroke Scale]

value: 0

component

code: Sensory [NIH Stroke Scale]

value: 1

component

code: Best language [NIH Stroke Scale]

value: 1

component

code: Dysarthria [NIH Stroke Scale]

value: 1

component

code: Extinction and inattention [NIH Stroke Scale]

value: 0


Entry 21 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-nihss-24h-example

Resource Observation:

腦中風-評估時點: 24h

status: Final

category: Survey

code: Total score [NIH Stroke Scale]

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-16 11:00:00+0800

value: 6

component

code: Level of consciousness [NIH Stroke Scale]

value: 0

component

code: LOC questions [NIH Stroke Scale]

value: 0

component

code: LOC commands [NIH Stroke Scale]

value: 0

component

code: Best gaze [NIH Stroke Scale]

value: 0

component

code: Visual [NIH Stroke Scale]

value: 0

component

code: Facial palsy [NIH Stroke Scale]

value: 1

component

code: Motor arm Left arm [NIH Stroke Scale]

value: 0

component

code: Motor arm Right arm [NIH Stroke Scale]

value: 2

component

code: Motor leg Leg - left [NIH Stroke Scale]

value: 0

component

code: Motor leg Leg - right [NIH Stroke Scale]

value: 1

component

code: Limb ataxia [NIH Stroke Scale]

value: 0

component

code: Sensory [NIH Stroke Scale]

value: 1

component

code: Best language [NIH Stroke Scale]

value: 1

component

code: Dysarthria [NIH Stroke Scale]

value: X

component

code: Extinction and inattention [NIH Stroke Scale]

value: 0


Entry 22 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-mrs-discharge-example

Resource Observation:

腦中風-評估時點: discharge

status: Final

category: Survey

code: Modified rankin scale

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-28

value: 3


Entry 23 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-mrs-unclassified-example

Resource Observation:

腦中風-評估時點: unclassified

腦中風-評估序號: 4

status: Final

category: Survey

code: Modified rankin scale

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

effective: 2025-04-20

value: 2


Entry 24 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-gcs-example

Resource Observation:

腦中風-評估時點: admission

status: Final

category: Survey

code: Glasgow coma score total

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15 08:35:00+0800

component

code: Glasgow coma score eye opening

value: 3

component

code: Glasgow coma score verbal

value: 4

component

code: Glasgow coma score motor

value: 6


Entry 25 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-body-height-example

Resource Observation:

status: Final

category: Vital Signs

code: Body height

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15 08:40:00+0800

value: 165.5 cm (Details: UCUM codecm = 'cm')


Entry 26 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-body-weight-example

Resource Observation:

status: Final

category: Vital Signs

code: Body weight

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15 08:40:00+0800

value: 62.3 kg (Details: UCUM codekg = 'kg')


Entry 27 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-body-temperature-example

Resource Observation:

status: Final

category: Vital Signs

code: Body temperature

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15 08:35:00+0800

value: 36.8 °C (Details: UCUM codeCel = 'Cel')


Entry 28 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-heart-rate-example

Resource Observation:

status: Final

category: Vital Signs

code: Heart rate

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15 08:35:00+0800

value: 88 /min (Details: UCUM code/min = '/min')


Entry 29 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-respiratory-rate-example

Resource Observation:

status: Final

category: Vital Signs

code: Respiratory rate

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15 08:35:00+0800

value: 18 /min (Details: UCUM code/min = '/min')


Entry 30 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-blood-pressure-example

Resource Observation:

status: Final

category: Vital Signs

code: Blood pressure panel with all children optional

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15 08:35:00+0800

component

code: Systolic blood pressure

value: 168 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')

component

code: Diastolic blood pressure

value: 95 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')


Entry 31 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-occupation-example

Resource Observation:

status: Final

category: Social History

code: History of Occupation

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

value: 退休


Entry 32 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-smoking-status-example

Resource Observation:

status: Final

category: Social History

code: Tobacco smoking status

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15

value: Ex-smoker


Entry 33 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-lab-hemoglobin-example

Resource Observation:

status: Final

category: Laboratory

code: 血紅素(Hb)

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15 09:50:00+0800

value: 13.2


Entry 34 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-lab-inr-not-available-example

Resource Observation:

status: Final

category: Laboratory

code: 凝血酶原時間國際標準化比值(INR)

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

effective: 2025-01-15 09:50:00+0800

dataAbsentReason: Unknown


Entry 35 - fullUrl = http://vgh-stroke-ig.fhir.tw/Observation/stroke-reperfusion-time-only-example

Resource Observation:

status: Final

category: Procedure

code: 再灌流時間

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28

value: 腦中風-來源事件時間: 11:50:00


Entry 36 - fullUrl = http://vgh-stroke-ig.fhir.tw/MedicationStatement/stroke-medstatement-statin-pre-admission-example

Resource MedicationStatement:

腦中風-用藥紀錄時窗: pre-admission

status: not-taken

status: recorded

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))


Entry 37 - fullUrl = http://vgh-stroke-ig.fhir.tw/MedicationStatement/stroke-medstatement-aspirin-inpatient-example

Resource MedicationStatement:

腦中風-用藥紀錄時窗: inpatient

status: unknown

status: recorded

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

note:

來源記錄有使用


Entry 38 - fullUrl = http://vgh-stroke-ig.fhir.tw/MedicationStatement/stroke-medstatement-apixaban-discharge-example

Resource MedicationStatement:

腦中風-用藥紀錄時窗: discharge

status: unknown

status: recorded

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

note:

來源記錄有使用


Entry 39 - fullUrl = http://vgh-stroke-ig.fhir.tw/MedicationAdministration/stroke-medadmin-ivtpa-example

Resource MedicationAdministration:

status: completed

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

Dosages

-TextDose
*45 mg45 mg (Details: UCUM codemg = 'mg')

Entry 40 - fullUrl = http://vgh-stroke-ig.fhir.tw/Procedure/stroke-procedure-evt-example

Resource Procedure:

status: Completed

code: 動脈內血栓移除術

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28


Entry 41 - fullUrl = http://vgh-stroke-ig.fhir.tw/Procedure/stroke-procedure-dysphagia-screening-example

Resource Procedure:

status: Completed

code: 吞嚥篩檢

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28


Entry 42 - fullUrl = http://vgh-stroke-ig.fhir.tw/Procedure/stroke-procedure-ventilation-not-done-example

Resource Procedure:

status: Not Done

code: 使用呼吸器

subject: Anonymous Patient Male, DoB: 1950-01 ( Medical record number: EX00000001 (use: official))

encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); period = 2025-01-15 --> 2025-01-28