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

: 門診單架構 - XML Representation

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<Composition xmlns="http://hl7.org/fhir">
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  <meta>
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    <profile
             value="https://www.nricm.edu.tw/twcm/StructureDefinition/composition-twcm"/>
    <profile
             value="https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Composition-twcore"/>
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  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><h3><b>中醫門診單</b></h3><p><b>病歷表單版本</b>:1</p><p><b>臨床狀態</b>:Final <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://hl7.org/fhir/composition-status">CompositionStatus</a>#final)</span></p><p><b>種類</b>:Outpatient Note <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="https://loinc.org/">LOINC</a>#34108-1)</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>就醫事件</b>:<a href="Encounter-EncounterTWCM-min.html">Encounter/EncounterTWCM-min</a></p><p><b>文件產生時間</b>:2010-04-21T14:30:00+08:00</p><p><b>醫事機構代碼</b>:<a href="Organization-OrganizationTWCM-min.html">OrganizationTWCM-min</a> &quot;3801012567&quot;<br/><b>醫事機構名稱</b>:<a href="Organization-OrganizationTWCM-min.html">OrganizationTWCM-min</a> &quot;捷達世中醫診所&quot;</p><p><b>文件標題</b>:中醫門診單</p><p><b>文件敏感性</b>:normal <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="http://terminology.hl7.org/CodeSystem/v3-Confidentiality/">v3 Code System Confidentiality</a>#N)</span></p><p><b>病摘小節內容:</b></p><blockquote><p><b>section[PatientInformation]:</b><br/><span style="display: block; margin-left: 20px;"><b>section[educationlevel]</b>: <a href="Observation-ObservationEducationLevelTWCM-min.html">Observation/ObservationEducationLevelTWCM-min</a><br/><b>section[occupation]</b>: <a href="Observation-ObservationOccupationTWCM-min.html">Observation/ObservationOccupationTWCM-min</a><br/><b>section[bloodtype]</b>: <a href="Observation-ObservationBloodtypeTWCM-min.html">Observation/ObservationBloodtypeTWCM-min</a></span></p><p><b>section[AllergyIntolerance]</b>: <a href="AllergyIntolerance-AllergyIntoleranceTWCM-min.html">AllergyIntolerance/AllergyIntoleranceTWCM-min</a></p><p><b>section[ConditionPastMedicalHistory]</b>: <a href="Condition-ConditionPastMedicalHistoryTWCM-min.html">Condition/ConditionPastMedicalHistoryTWCM-min</a></p><p><b>section[ConditionMajorIllness]</b>: <a href="Observation-ObservationMajorIllnessTWCM-min.html">Observation/ObservationMajorIllnessTWCM-min</a></p><p><b>section[Medication]</b>:<br/><span style="display: block; margin-left: 20px;"><b>section[medication]</b>: <a href="Medication-MedicationTWCM-min.html">Medication/MedicationTWCM-min</a><br/><b>section[medication]</b>: <a href="Medication-MedicationTWCM-pro.html">Medication/MedicationTWCM-pro</a><br/><b>section[medicationrequest]</b>: <a href="MedicationRequest-MedicationRequestTWCM-min.html">MedicationRequest/MedicationRequestTWCM-min</a><br/><b>section[medicationrequest]</b>: <a href="MedicationRequest-MedicationRequestTWCM-pro.html">MedicationRequest/MedicationRequestTWCM-pro</a></span></p><p><b>section[ConditionDiagnosis]</b>:<br/><span style="display: block; margin-left: 20px;"><b>section[conditiondiagnosis]</b>: <a href="Condition-ConditionDiagnosisTWCM-min.html">Condition/ConditionDiagnosisTWCM-min</a><br/><b>section[practitioner]</b>: <a href="Practitioner-PractitionerTWCM-pro.html">Practitioner/PractitionerTWCM-pro</a><br/><b>section[careplan]</b>: <a href="CarePlan-CarePlanTWCM-min.html">CarePlan/CarePlanTWCM-min</a><br/><b>section[observationtonguecondition]</b>: <a href="Observation-ObservationTongueConditionTWCM-min.html">Observation/ObservationTongueConditionTWCM-min</a><br/><b>section[observationpulsecondition]</b>: <a href="Observation-ObservationPulseConditionTWCM-min.html">Observation/ObservationPulseConditionTWCM-min</a><br/><b>section[observationsyndrometype]</b>: <a href="Observation-ObservationSyndromeTypeTWCM-min.html">Observation/ObservationSyndromeTypeTWCM-min</a><br/><b>section[observationtherapeuticprinciples]</b>: <a href="Observation-ObservationTherapeuticPrinciplesTWCM-min.html">Observation/ObservationTherapeuticPrinciplesTWCM-min</a><br/></span></p><p><b>section[ConditionChiefComplaint]</b>: <a href="Condition-ConditionChiefComplaintTWCM-min.html">Condition/ConditionChiefComplaintTWCM-min</a></p><p><b>section[ObservationVitalSign]</b>: <a href="Observation-ObservationVitalSignTWCM-min.html">Observation/ObservationVitalSignTWCM-min</a></p><p><b>section[Procedure]</b>: <a href="Procedure-ProcedureTWCM-min.html">Procedure/ProcedureTWCM-min</a><br/><b>section[Procedure]</b>: <a href="Procedure-ProcedureTWCM-minn.html">Procedure/ProcedureTWCM-minn</a><br/><b>section[Procedure]</b>: <a href="Procedure-ProcedureTWCM-pro.html">Procedure/ProcedureTWCM-pro</a></p><p><b>section[ObservationLabResults]</b>:<br/><span style="display: block; margin-left: 20px;"><b>section[observation]</b>: <a href="Observation-ObservationTWCM-min.html">Observation/ObservationTWCM-min</a><br/><b>section[observation]</b>: <a href="Observation-ObservationTWCM-pro.html">Observation/ObservationTWCM-pro</a><br/><b>section[servicerequest]</b>: <a href="ServiceRequest-ServiceRequestTWCM-min.html">ServiceRequest/ServiceRequestTWCM-min</a><br/><b>section[servicerequest]</b>: <a href="ServiceRequest-ServiceRequestTWCM-pro.html">ServiceRequest/ServiceRequestTWCM-pro</a><br/><b>section[diagnosticreport]</b>: <a href="DiagnosticReport-DiagnosticReportTWCM-min.html">DiagnosticReport/DiagnosticReportTWCM-min</a><br/><b>section[organizationinspection]</b>: <a href="Organization-OrganizationInspectionTWCM-min.html">Organization/OrganizationInspectionTWCM-min</a></span></p><p><b>section[DocumentReference]</b>: <a href="DocumentReference-DocumentReferenceTWCM-min.html">DocumentReference/DocumentReferenceTWCM-min</a></p></blockquote></div>
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  <subject>🔗 
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  <date value="2010-04-21T14:30:00+08:00"/>
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  <title value="中醫門診單"/>
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          <system value="http://loinc.org"/>
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          <display value="Occupation [Type]"/>
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          <system value="http://loinc.org"/>
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          <display value="ABO and Rh group [Type] in Blood"/>
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        <reference value="Observation/ObservationBloodtypeTWCM-min"/>
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        <system value="http://loinc.org"/>
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        <display value="History of Major illnesses and injuries Narrative"/>
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    <entry>🔗 
      <reference value="Observation/ObservationMajorIllnessTWCM-min"/>
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          <display value="Prescription for medication"/>
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      <entry>🔗 
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        <display value="Problem list - Reported"/>
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        <reference value="Condition/ConditionDiagnosisTWCM-min"/>
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          <display value="Primary practitioner identifier"/>
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          <display value="Multidisciplinary Comprehensive plan of care note"/>
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    <title value="病人主訴"/>
    <code>
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        <display value="Chief complaint Narrative - Reported"/>
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    <entry>🔗 
      <reference value="Condition/ConditionChiefComplaintTWCM-min"/>
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  <section>
    <title value="生命徵象"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="8716-3"/>
        <display value="Vital signs note"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="Observation/ObservationVitalSignTWCM-min"/>
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      <coding>
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    <entry>🔗 
      <reference value="Procedure/ProcedureTWCM-minn"/>
    </entry>
    <entry>🔗 
      <reference value="Procedure/ProcedureTWCM-pro"/>
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  <section>
    <title value="實驗室檢驗檢查紀錄"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="30954-2"/>
        <display value="Relevant diagnostic tests/laboratory data note"/>
      </coding>
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    <section>
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        <coding>
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          <display value="Referral lab test results"/>
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          <display value="Orders placed Document"/>
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          <display value="Narrative diagnostic report [Interpretation]"/>
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    <section>
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        <display value="Health concerns Document"/>
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