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

: 問診範例 - JSON Representation

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{
  "resourceType" : "Observation",
  "id" : "ObservationInquiryTWCM-min",
  "meta" : {
    "profile" : [
      🔗 "https://www.nricm.edu.tw/twcm/StructureDefinition/observationinquiry-twcm"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3><b>問診</b></h3><p><b>狀態</b>：Final <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">( <a href=\"http://hl7.org/fhir/observation-status\">ObservationStatus</a>#final)</span></p><p><b>項目</b>：Finding reported by subject or history provider <span style=\"background: LightGoldenRodYellow;\">( <a href=\"http://snomed.info/sct\">SNOMED CT Code</a>#418799008)</span></p><p><b>病人</b>：<a href=\"Patient-PatientTWCM-min.html\">Patient/PatientTWCM-min</a> \"陳美真\"</p><p><b>紀錄時間</b>：2010-10-10T17:30:00-05:00</p><p><b>問診描述</b>：惡寒發熱，鼻塞流清涕，納差，大便溏，夜寐尚可</p><p><b>問診分類紀錄</b>：<br/>寒熱(問)：惡寒發熱 <span style=\"background: LightGoldenRodYellow;\">( <a href=\"CodeSystem-twcm-clinicalfinding.html\">中醫臨床表現詞彙</a>#惡寒發熱)</span><br/>鼻咽部(問)：鼻塞 <span style=\"background: LightGoldenRodYellow;\">( <a href=\"CodeSystem-twcm-clinicalfinding.html\">中醫臨床表現詞彙</a>#鼻塞)</span><br/>飲食／口味(問)：納呆(納差、納少) <span style=\"background: LightGoldenRodYellow;\">( <a href=\"CodeSystem-twcm-clinicalfinding.html\">中醫臨床表現詞彙</a>#納呆(納差、納少))</span><br/>大便(問)：大便溏 <span style=\"background: LightGoldenRodYellow;\">( <a href=\"CodeSystem-twcm-clinicalfinding.html\">中醫臨床表現詞彙</a>#大便溏)</span></p><p><b>就醫事件</b>：<a href=\"Encounter-EncounterTWCM-min.html\">Encounter/EncounterTWCM-min</a></p></div>"
  },
  "status" : "final",
  "code" : {
    "coding" : [
      {
        "system" : "http://snomed.info/sct",
        "code" : "418799008",
        "display" : "Finding reported by subject or history provider"
      }
    ]
  },
  "subject" : {
    🔗 "reference" : "Patient/PatientTWCM-min"
  },
  "encounter" : {
    🔗 "reference" : "Encounter/EncounterTWCM-min"
  },
  "effectiveDateTime" : "2010-10-10T17:30:00-05:00",
  "valueString" : "惡寒發熱，鼻塞流清涕，納差，大便溏，夜寐尚可",
  "component" : [
    {
      "code" : {
        "coding" : [
          {
            "system" : "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-fourdiagnosis-category",
            "code" : "問寒熱",
            "display" : "寒熱(問)"
          }
        ]
      },
      "valueCodeableConcept" : {
        "coding" : [
          {
            "system" : "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-clinicalfinding",
            "code" : "惡寒發熱",
            "display" : "惡寒發熱"
          }
        ],
        "text" : "惡寒發熱"
      }
    },
    {
      "code" : {
        "coding" : [
          {
            "system" : "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-fourdiagnosis-category",
            "code" : "問鼻咽",
            "display" : "鼻咽部(問)"
          }
        ]
      },
      "valueCodeableConcept" : {
        "coding" : [
          {
            "system" : "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-clinicalfinding",
            "code" : "鼻塞",
            "display" : "鼻塞"
          }
        ],
        "text" : "鼻塞"
      }
    },
    {
      "code" : {
        "coding" : [
          {
            "system" : "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-fourdiagnosis-category",
            "code" : "問飲食口味",
            "display" : "飲食／口味(問)"
          }
        ]
      },
      "valueCodeableConcept" : {
        "coding" : [
          {
            "system" : "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-clinicalfinding",
            "code" : "納呆(納差、納少)",
            "display" : "納呆(納差、納少)"
          }
        ],
        "text" : "納呆(納差、納少)"
      }
    },
    {
      "code" : {
        "coding" : [
          {
            "system" : "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-fourdiagnosis-category",
            "code" : "問大便",
            "display" : "大便(問)"
          }
        ]
      },
      "valueCodeableConcept" : {
        "coding" : [
          {
            "system" : "https://www.nricm.edu.tw/twcm/CodeSystem/twcm-clinicalfinding",
            "code" : "大便溏",
            "display" : "大便溏"
          }
        ],
        "text" : "大便溏"
      }
    }
  ]
}