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

: 望診範例 - XML Representation

Raw xml | Download


<Observation xmlns="http://hl7.org/fhir">
  <id value="ObservationInspectionTWCM-min"/>
  <meta>
    <profile
             value="https://www.nricm.edu.tw/twcm/StructureDefinition/observationinspection-twcm"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><h3><b>望診</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 by inspection (simple observation) <span style="background: LightGoldenRodYellow;">( <a href="http://snomed.info/sct">SNOMED CT Code</a>#118243007)</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>望診描述</b>：神清，面色萎黃，形體偏瘦</p><p><b>病人舌象</b>：<br/>苔白（Coating of mucous membrane of tongue <span style="background: LightGoldenRodYellow;">( <a href="CodeSystem-twcm-tonguecondition.html">病人舌象</a>#698193000) </span>）<br/>舌淡紅，舌邊有齒痕（此描述無法對應至單一SNOMED CT代碼，故僅記錄文字）</p><p><b>望診分類紀錄</b>：<br/>精神／意識／行為／情緒／性格(望神)：神疲 <span style="background: LightGoldenRodYellow;">( <a href="CodeSystem-twcm-clinicalfinding.html">中醫臨床表現詞彙</a>#神疲)</span><br/>頭面部(望)：面色萎黃 <span style="background: LightGoldenRodYellow;">( <a href="CodeSystem-twcm-clinicalfinding.html">中醫臨床表現詞彙</a>#面色萎黃)</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="118243007"/>
      <display value="Finding by inspection (simple observation)"/>
    </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="神清，面色萎黃，形體偏瘦"/>
  <component>
    <code>
      <coding>
        <system
                value="https://www.nricm.edu.tw/twcm/CodeSystem/twcm-fourdiagnosis-category"/>
        <code value="望神"/>
        <display value="精神／意識／行為／情緒／性格(望神)"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="https://www.nricm.edu.tw/twcm/CodeSystem/twcm-clinicalfinding"/>
        <code value="神疲"/>
        <display value="神疲"/>
      </coding>
      <text value="神疲"/>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system
                value="https://www.nricm.edu.tw/twcm/CodeSystem/twcm-fourdiagnosis-category"/>
        <code value="望頭面"/>
        <display value="頭面部(望)"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="https://www.nricm.edu.tw/twcm/CodeSystem/twcm-clinicalfinding"/>
        <code value="面色萎黃"/>
        <display value="面色萎黃"/>
      </coding>
      <text value="面色萎黃"/>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="249378009"/>
        <display value="Tongue finding"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="https://www.nricm.edu.tw/twcm/CodeSystem/twcm-tonguecondition"/>
        <code value="698193000"/>
        <display value="Coating of mucous membrane of tongue"/>
      </coding>
      <text value="苔白"/>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="249378009"/>
        <display value="Tongue finding"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <text value="舌淡紅，舌邊有齒痕"/>
    </valueCodeableConcept>
  </component>
</Observation>