臺灣中醫實作指引
0.1.0 - ci-build
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
病歷表單版本：1
臨床狀態：Final (CompositionStatus#final)
種類：Outpatient Note ( LOINC#34108-1)
病人：Patient/PatientTWCM-min "陳美真"
就醫事件：Encounter/EncounterTWCM-min
文件產生時間：2010-04-21T14:30:00+08:00
醫事機構代碼：OrganizationTWCM-min "3801012567"
醫事機構名稱：OrganizationTWCM-min "捷達世中醫診所"
文件標題：中醫門診單
文件敏感性：normal ( v3 Code System Confidentiality#N)
病摘小節內容：
section[PatientInformation]： Patient/PatientTWCM-min
section[AllergyIntolerance]： AllergyIntolerance/AllergyIntoleranceTWCM-min
section[MedicalHistory]： Condition/ConditionMedicalHistoryTWCM-min、Condition/ConditionMedicalHistoryTWCM-menstrual、Condition/ConditionMedicalHistoryTWCM-obstetric、Condition/ConditionMedicalHistoryTWCM-pediatric
section[ConditionMajorIllness]： Observation/ObservationMajorIllnessTWCM-min
section： Condition/ConditionMajorIllnessTWCM-minsection[Medication]：
section[medication]： Medication/MedicationTWCM-min
section[medication]： Medication/MedicationTWCM-pro
section[medicationrequest]： MedicationRequest/MedicationRequestTWCM-min
section[medicationrequest]： MedicationRequest/MedicationRequestTWCM-prosection[ConditionDiagnosis]：
section[conditiondiagnosis]： Condition/ConditionDiagnosisTWCM-min、Condition/ConditionSyndromeTypeTWCM-min
section[practitioner]： Practitioner/PractitionerTWCM-prosection[PhysicalFindings]： Observation/ObservationPulseConditionTWCM-min、Observation/ObservationPulseConditionTWCM-lefthand
section[PlanOfCare]： CarePlan/CarePlanTWCM-min、Procedure/ProcedureTherapeuticPrinciplesTWCM-min
section[ConditionChiefComplaint]： Condition/ConditionChiefComplaintTWCM-min
section[PresentIllness]： Condition/ConditionMedicalHistoryTWCM-present
section[ObservationVitalSign]： Observation/ObservationVitalSignTWCM-min
section[Procedure]： Procedure/ProcedureTWCM-min
section[Procedure]： Procedure/ProcedureTWCM-minn
section[Procedure]： Procedure/ProcedureTWCM-prosection[ObservationLabResults]：
section[observation]： Observation/ObservationTWCM-min
section[observation]： Observation/ObservationTWCM-pro
section[servicerequest]： ServiceRequest/ServiceRequestTWCM-min
section[servicerequest]： ServiceRequest/ServiceRequestTWCM-pro
section[diagnosticreport]： DiagnosticReport/DiagnosticReportTWCM-min
section[bloodtype]： Observation/ObservationBloodtypeTWCM-minsection[DocumentReference]： DocumentReference/DocumentReferenceTWCM-min
section[FamilyMemberHistory]： FamilyMemberHistory/FamilyMemberHistoryTWCM-min
section[SocialHistory]： Observation/ObservationSocialHistoryTWCM-min
section[occupation]： Observation/ObservationOccupationTWCM-min
section[educationlevel]： Observation/ObservationEducationLevelTWCM-minsection[Objective]：
ClinicalImpression/ClinicalImpressionTWCM-min
Observation/ObservationInspectionTWCM-min
Observation/ObservationListeningSmellingTWCM-min
Observation/ObservationInquiryTWCM-min
Observation/ObservationPalpationTWCM-min