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 - XML Representation

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<ClinicalImpression xmlns="http://hl7.org/fhir">
  <id value="ClinicalImpressionTWCM-min"/>
  <meta>
    <profile
             value="https://www.nricm.edu.tw/twcm/StructureDefinition/clinicalimpression-twcm"/>
  </meta>
  <text>
    <status value="generated"/>
    <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> &quot;陳美真&quot;</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> &quot;外感風寒,脾失健運&quot;</p><p><b>就醫事件</b>：<a href="Encounter-EncounterTWCM-min.html">Encounter/EncounterTWCM-min</a></p></div>
  </text>
  <status value="completed"/>
  <subject>🔗 
    <reference value="Patient/PatientTWCM-min"/>
  </subject>
  <encounter>🔗 
    <reference value="Encounter/EncounterTWCM-min"/>
  </encounter>
  <effectiveDateTime value="2010-10-10T17:30:00-05:00"/>
  <investigation>
    <code>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="118243007"/>
        <display value="Finding by inspection (simple observation)"/>
      </coding>
    </code>
    <item>🔗 
      <reference value="Observation/ObservationInspectionTWCM-min"/>
    </item>
  </investigation>
  <investigation>
    <code>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="118241009"/>
        <display value="Finding by auscultation"/>
      </coding>
    </code>
    <item>🔗 
      <reference value="Observation/ObservationListeningSmellingTWCM-min"/>
    </item>
  </investigation>
  <investigation>
    <code>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="418799008"/>
        <display value="Finding reported by subject or history provider"/>
      </coding>
    </code>
    <item>🔗 
      <reference value="Observation/ObservationInquiryTWCM-min"/>
    </item>
  </investigation>
  <investigation>
    <code>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="118242002"/>
        <display value="Finding by palpation"/>
      </coding>
    </code>
    <item>🔗 
      <reference value="Observation/ObservationPalpationTWCM-min"/>
    </item>
  </investigation>
  <summary value="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 value="病因"/>
    </itemCodeableConcept>
    <basis value="外感風寒，飲食失調"/>
  </finding>
  <finding>
    <itemCodeableConcept>
      <text value="病性"/>
    </itemCodeableConcept>
    <basis value="表寒兼脾虛，虛實夾雜"/>
  </finding>
  <finding>
    <itemCodeableConcept>
      <text value="病位"/>
    </itemCodeableConcept>
    <basis value="肺、脾"/>
  </finding>
  <finding>
    <itemCodeableConcept>
      <text value="病勢"/>
    </itemCodeableConcept>
    <basis value="病程尚短，持續治療中"/>
  </finding>
  <finding>
    <itemCodeableConcept>
      <text value="證型"/>
    </itemCodeableConcept>
    <itemReference>🔗 
      <reference value="Condition/ConditionSyndromeTypeTWCM-min"/>
    </itemReference>
  </finding>
</ClinicalImpression>