臺灣核心實作指引(TW Core IG), published by 衛生福利部. This guide is not an authorized publication; it is the continuous build for version 0.3.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cctwFHIRterm/MOHW_TWCoreIG_Build/ and changes regularly. See the Directory of published versions
臨床狀態:Final (CompositionStatus#final)
種類:Medical records ( LOINC#11503-0)
分類: Hospital Admission history and physical note ( LOINC#47039-3)
病人:Patient/pat-example "陳加玲"
編輯時間:2023-09-10T10:30:00
病摘創建者:Practitioner/pra-dr-example "王依昇"
根據特定技術領域的定義:restricted ( v3 Code System Confidentiality#R)
證明準確性:
認證者提供的認證類型:Personal ( CompositionAttestationMode#personal)
被證明的時間:2023-09-10T11:00:00
負責證明的人員:Practitioner/pra-dr-example "王依昇"
負責維護機構:Organization/org-hosp-example "衛生福利部臺北醫院"
正在記錄的臨床服務:
被記錄的主要臨床行為代碼:medication list ( ActCode#MEDLIST)
文件所涵蓋的時間區間:2023-09-10T08:00:00 ~ 2023-09-15T09:30:00
病摘小節內容:
section.entry[Observation]:Observation/obs-bloodPressure-example
section.entry[Practitioner]:Practitioner/pra-dr-example
section.entry[MedicationRequest]:MedicationRequest/med-req-cod-example