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
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<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> "陳美真"</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> "3801012567"<br/><b>醫事機構名稱</b>:<a href="Organization-OrganizationTWCM-min.html">OrganizationTWCM-min</a> "捷達世中醫診所"</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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