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 - XML Representation

Raw xml | Download


<Observation xmlns="http://hl7.org/fhir">
  <id value="ObservationInquiryTWCM-min"/>
  <meta>
    <profile
             value="https://www.nricm.edu.tw/twcm/StructureDefinition/observationinquiry-twcm"/>
  </meta>
  <text>
    <status value="generated"/>
    <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> &quot;陳美真&quot;</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>
  </text>
  <status value="final"/>
  <code>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="418799008"/>
      <display value="Finding reported by subject or history provider"/>
    </coding>
  </code>
  <subject>🔗 
    <reference value="Patient/PatientTWCM-min"/>
  </subject>
  <encounter>🔗 
    <reference value="Encounter/EncounterTWCM-min"/>
  </encounter>
  <effectiveDateTime value="2010-10-10T17:30:00-05:00"/>
  <valueString value="惡寒發熱，鼻塞流清涕，納差，大便溏，夜寐尚可"/>
  <component>
    <code>
      <coding>
        <system
                value="https://www.nricm.edu.tw/twcm/CodeSystem/twcm-fourdiagnosis-category"/>
        <code value="問寒熱"/>
        <display value="寒熱(問)"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="https://www.nricm.edu.tw/twcm/CodeSystem/twcm-clinicalfinding"/>
        <code value="惡寒發熱"/>
        <display value="惡寒發熱"/>
      </coding>
      <text value="惡寒發熱"/>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system
                value="https://www.nricm.edu.tw/twcm/CodeSystem/twcm-fourdiagnosis-category"/>
        <code value="問鼻咽"/>
        <display value="鼻咽部(問)"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="https://www.nricm.edu.tw/twcm/CodeSystem/twcm-clinicalfinding"/>
        <code value="鼻塞"/>
        <display value="鼻塞"/>
      </coding>
      <text value="鼻塞"/>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system
                value="https://www.nricm.edu.tw/twcm/CodeSystem/twcm-fourdiagnosis-category"/>
        <code value="問飲食口味"/>
        <display value="飲食／口味(問)"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="https://www.nricm.edu.tw/twcm/CodeSystem/twcm-clinicalfinding"/>
        <code value="納呆(納差、納少)"/>
        <display value="納呆(納差、納少)"/>
      </coding>
      <text value="納呆(納差、納少)"/>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system
                value="https://www.nricm.edu.tw/twcm/CodeSystem/twcm-fourdiagnosis-category"/>
        <code value="問大便"/>
        <display value="大便(問)"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="https://www.nricm.edu.tw/twcm/CodeSystem/twcm-clinicalfinding"/>
        <code value="大便溏"/>
        <display value="大便溏"/>
      </coding>
      <text value="大便溏"/>
    </valueCodeableConcept>
  </component>
</Observation>