臺灣中醫實作指引
0.1.0 - ci-build

臺灣中醫實作指引, published by 衛生福利部國家中醫藥研究所. 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/nricmig/Nricm_TWCMIG/ and changes regularly. See the Directory of published versions

: 中醫辨證評估範例 - JSON Representation

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{
  "resourceType" : "ClinicalImpression",
  "id" : "ClinicalImpressionTWCM-min",
  "meta" : {
    "profile" : [
      🔗 "https://www.nricm.edu.tw/twcm/StructureDefinition/clinicalimpression-twcm"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>中醫辨證評估</b></h3><p><b>狀態</b>：Completed <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://hl7.org/fhir/clinicalimpression-status\">ClinicalImpressionStatus</a>#completed)</span></p><p><b>病人</b>：<a href=\"Patient-PatientTWCM-min.html\">Patient/PatientTWCM-min</a> \"陳美真\"</p><p><b>評估時間</b>：2010-10-10T17:30:00-05:00</p><p><b>望聞問切客觀描述</b>：神清，面色萎黃，形體偏瘦，語聲低微，腹部按之柔軟無壓痛</p><p><b>四診紀錄</b>：<br/>望診：<a href=\"Observation-ObservationInspectionTWCM-min.html\">Observation/ObservationInspectionTWCM-min</a><br/>聞診：<a href=\"Observation-ObservationListeningSmellingTWCM-min.html\">Observation/ObservationListeningSmellingTWCM-min</a><br/>問診：<a href=\"Observation-ObservationInquiryTWCM-min.html\">Observation/ObservationInquiryTWCM-min</a><br/>切診：<a href=\"Observation-ObservationPalpationTWCM-min.html\">Observation/ObservationPalpationTWCM-min</a></p><p><b>辨證結果</b>：<br/>病因：外感風寒，飲食失調<br/>病性：表寒兼脾虛，虛實夾雜<br/>病位：肺、脾<br/>病勢：病程尚短，持續治療中<br/>證型：<a href=\"Condition-ConditionSyndromeTypeTWCM-min.html\">Condition/ConditionSyndromeTypeTWCM-min</a> \"外感風寒,脾失健運\"</p><p><b>就醫事件</b>：<a href=\"Encounter-EncounterTWCM-min.html\">Encounter/EncounterTWCM-min</a></p></div>"
  },
  "status" : "completed",
  "subject" : {
    🔗 "reference" : "Patient/PatientTWCM-min"
  },
  "encounter" : {
    🔗 "reference" : "Encounter/EncounterTWCM-min"
  },
  "effectiveDateTime" : "2010-10-10T17:30:00-05:00",
  "investigation" : [
    {
      "code" : {
        "coding" : [
          {
            "system" : "http://snomed.info/sct",
            "code" : "118243007",
            "display" : "Finding by inspection (simple observation)"
          }
        ]
      },
      "item" : [
        {
          🔗 "reference" : "Observation/ObservationInspectionTWCM-min"
        }
      ]
    },
    {
      "code" : {
        "coding" : [
          {
            "system" : "http://snomed.info/sct",
            "code" : "118241009",
            "display" : "Finding by auscultation"
          }
        ]
      },
      "item" : [
        {
          🔗 "reference" : "Observation/ObservationListeningSmellingTWCM-min"
        }
      ]
    },
    {
      "code" : {
        "coding" : [
          {
            "system" : "http://snomed.info/sct",
            "code" : "418799008",
            "display" : "Finding reported by subject or history provider"
          }
        ]
      },
      "item" : [
        {
          🔗 "reference" : "Observation/ObservationInquiryTWCM-min"
        }
      ]
    },
    {
      "code" : {
        "coding" : [
          {
            "system" : "http://snomed.info/sct",
            "code" : "118242002",
            "display" : "Finding by palpation"
          }
        ]
      },
      "item" : [
        {
          🔗 "reference" : "Observation/ObservationPalpationTWCM-min"
        }
      ]
    }
  ],
  "summary" : "神清，面色萎黃，形體偏瘦，語聲低微，腹部按之柔軟無壓痛",
  "finding" : [
    {
      "itemCodeableConcept" : {
        "text" : "病因"
      },
      "basis" : "外感風寒，飲食失調"
    },
    {
      "itemCodeableConcept" : {
        "text" : "病性"
      },
      "basis" : "表寒兼脾虛，虛實夾雜"
    },
    {
      "itemCodeableConcept" : {
        "text" : "病位"
      },
      "basis" : "肺、脾"
    },
    {
      "itemCodeableConcept" : {
        "text" : "病勢"
      },
      "basis" : "病程尚短，持續治療中"
    },
    {
      "itemCodeableConcept" : {
        "text" : "證型"
      },
      "itemReference" : {
        🔗 "reference" : "Condition/ConditionSyndromeTypeTWCM-min"
      }
    }
  ]
}