{ "resourceType" : "Composition", "id" : "CompositionTWCM-min", "meta" : { "versionId" : "1", "profile" : ["https://www.nricm.edu.tw/twcm/StructureDefinition/composition-twcm", "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Composition-twcore"] }, "text" : { "status" : "generated", "div" : "

中醫門診單

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]：
section[educationlevel]： Observation/ObservationEducationLevelTWCM-min
section[occupation]： Observation/ObservationOccupationTWCM-min
section[bloodtype]： Observation/ObservationBloodtypeTWCM-min

section[AllergyIntolerance]： AllergyIntolerance/AllergyIntoleranceTWCM-min

section[ConditionPastMedicalHistory]： Condition/ConditionPastMedicalHistoryTWCM-min

section[ConditionMajorIllness]： Observation/ObservationMajorIllnessTWCM-min

section[Medication]：
section[medication]： Medication/MedicationTWCM-min
section[medication]： Medication/MedicationTWCM-pro
section[medicationrequest]： MedicationRequest/MedicationRequestTWCM-min
section[medicationrequest]： MedicationRequest/MedicationRequestTWCM-pro

section[ConditionDiagnosis]：
section[conditiondiagnosis]： Condition/ConditionDiagnosisTWCM-min
section[practitioner]： Practitioner/PractitionerTWCM-pro
section[careplan]： CarePlan/CarePlanTWCM-min
section[observationtonguecondition]： Observation/ObservationTongueConditionTWCM-min
section[observationpulsecondition]： Observation/ObservationPulseConditionTWCM-min
section[observationsyndrometype]： Observation/ObservationSyndromeTypeTWCM-min
section[observationtherapeuticprinciples]： Observation/ObservationTherapeuticPrinciplesTWCM-min

section[ConditionChiefComplaint]： Condition/ConditionChiefComplaintTWCM-min

section[ObservationVitalSign]： Observation/ObservationVitalSignTWCM-min

section[Procedure]： Procedure/ProcedureTWCM-min
section[Procedure]： Procedure/ProcedureTWCM-minn
section[Procedure]： Procedure/ProcedureTWCM-pro

section[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[organizationinspection]： Organization/OrganizationInspectionTWCM-min

section[DocumentReference]： DocumentReference/DocumentReferenceTWCM-min

" }, "identifier" : { "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v2-0203", "code" : "SNO" }] }, "value" : "TW.NRICM.Clinic.ChineseMedicine.1" }, "status" : "final", "type" : { "coding" : [{ "system" : "http://loinc.org", "code" : "34108-1", "display" : "Outpatient Note" }] }, "subject" : { "reference" : "Patient/PatientTWCM-min" }, "encounter" : { "reference" : "Encounter/EncounterTWCM-min" }, "date" : "2010-04-21T14:30:00+08:00", "author" : [{ "reference" : "Organization/OrganizationTWCM-min" }], "title" : "中醫門診單", "confidentiality" : "N", "section" : [{ "title" : "病人資料", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "52460-3", "display" : "Patient Information" }] }, "section" : [{ "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "80913-7", "display" : "Highest level of education [US Standard Certificate of Death]" }] }, "entry" : [{ "reference" : "Observation/ObservationEducationLevelTWCM-min" }] }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "85658-3", "display" : "Occupation [Type]" }] }, "entry" : [{ "reference" : "Observation/ObservationOccupationTWCM-min" }] }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "882-1", "display" : "ABO and Rh group [Type] in Blood" }] }, "entry" : [{ "reference" : "Observation/ObservationBloodtypeTWCM-min" }] }] }, { "title" : "過敏史", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "48765-2", "display" : "Allergies and adverse reactions Document" }] }, "entry" : [{ "reference" : "AllergyIntolerance/AllergyIntoleranceTWCM-min" }] }, { "title" : "過去病史", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "11348-0", "display" : "History of Past illness note" }] }, "entry" : [{ "reference" : "Condition/ConditionPastMedicalHistoryTWCM-min" }] }, { "title" : "重大傷病", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "11338-1", "display" : "History of Major illnesses and injuries Narrative" }] }, "entry" : [{ "reference" : "Observation/ObservationMajorIllnessTWCM-min" }] }, { "title" : "用藥紀錄", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "10160-0", "display" : "History of Medication use Narrative" }] }, "section" : [{ "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "87232-5", "display" : "Medication administration.brief" }] }, "entry" : [{ "reference" : "Medication/MedicationTWCM-min" }] }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "87232-5", "display" : "Medication administration.brief" }] }, "entry" : [{ "reference" : "Medication/MedicationTWCM-pro" }] }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "57833-6", "display" : "Prescription for medication" }] }, "entry" : [{ "reference" : "MedicationRequest/MedicationRequestTWCM-min" }] }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "57833-6", "display" : "Prescription for medication" }] }, "entry" : [{ "reference" : "MedicationRequest/MedicationRequestTWCM-pro" }] }] }, { "title" : "診斷", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "11450-4", "display" : "Problem list - Reported" }] }, "section" : [{ "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "29548-5", "display" : "Diagnosis Narrative" }] }, "entry" : [{ "reference" : "Condition/ConditionDiagnosisTWCM-min" }] }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "18600-7", "display" : "Primary practitioner identifier" }] }, "entry" : [{ "reference" : "Practitioner/PractitionerTWCM-pro" }] }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "101541-1", "display" : "Multidisciplinary Comprehensive plan of care note" }] }, "entry" : [{ "reference" : "CarePlan/CarePlanTWCM-min" }] }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "29548-5", "display" : "Diagnosis Narrative" }] }, "entry" : [{ "reference" : "Observation/ObservationTongueConditionTWCM-min" }] }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "29548-5", "display" : "Diagnosis Narrative" }] }, "entry" : [{ "reference" : "Observation/ObservationPulseConditionTWCM-min" }] }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "29548-5", "display" : "Diagnosis Narrative" }] }, "entry" : [{ "reference" : "Observation/ObservationSyndromeTypeTWCM-min" }] }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "29548-5", "display" : "Diagnosis Narrative" }] }, "entry" : [{ "reference" : "Observation/ObservationTherapeuticPrinciplesTWCM-min" }] }] }, { "title" : "病人主訴", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "10154-3", "display" : "Chief complaint Narrative - Reported" }] }, "entry" : [{ "reference" : "Condition/ConditionChiefComplaintTWCM-min" }] }, { "title" : "生命徵象", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "8716-3", "display" : "Vital signs note" }] }, "entry" : [{ "reference" : "Observation/ObservationVitalSignTWCM-min" }] }, { "title" : "處置或手術", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "29554-3", "display" : "Procedure Narrative" }] }, "entry" : [{ "reference" : "Procedure/ProcedureTWCM-min" }, { "reference" : "Procedure/ProcedureTWCM-minn" }, { "reference" : "Procedure/ProcedureTWCM-pro" }] }, { "title" : "實驗室檢驗檢查紀錄", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "30954-2", "display" : "Relevant diagnostic tests/laboratory data note" }] }, "section" : [{ "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "19146-0", "display" : "Referral lab test results" }] }, "entry" : [{ "reference" : "Observation/ObservationTWCM-min" }] }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "19146-0", "display" : "Referral lab test results" }] }, "entry" : [{ "reference" : "Observation/ObservationTWCM-pro" }] }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "77597-3", "display" : "Orders placed Document" }] }, "entry" : [{ "reference" : "ServiceRequest/ServiceRequestTWCM-min" }] }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "77597-3", "display" : "Orders placed Document" }] }, "entry" : [{ "reference" : "ServiceRequest/ServiceRequestTWCM-pro" }] }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "50398-7", "display" : "Narrative diagnostic report [Interpretation]" }] }, "entry" : [{ "reference" : "DiagnosticReport/DiagnosticReportTWCM-min" }] }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "52482-7", "display" : "Laboratory" }] }, "entry" : [{ "reference" : "Organization/OrganizationInspectionTWCM-min" }] }] }, { "title" : "健康問題文件", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "75310-3", "display" : "Health concerns Document" }] }, "entry" : [{ "reference" : "DocumentReference/DocumentReferenceTWCM-min" }] }] }