# 門診單架構 - 臺灣中醫實作指引 v0.1.0

* [**Table of Contents**](toc.md)
* [**Artifacts Summary**](artifacts.md)
* **門診單架構**

## Example Composition: 門診單架構

### 中醫門診單

**病歷表單版本**：1

**臨床狀態**：Final ([CompositionStatus](http://hl7.org/fhir/composition-status)#final)

**種類**：Outpatient Note ( [LOINC](https://loinc.org/)#34108-1)

**病人**：[Patient/PatientTWCM-min](Patient-PatientTWCM-min.md) "陳美真"

**就醫事件**：[Encounter/EncounterTWCM-min](Encounter-EncounterTWCM-min.md)

**文件產生時間**：2010-04-21T14:30:00+08:00

**醫事機構代碼**：[OrganizationTWCM-min](Organization-OrganizationTWCM-min.md) "3801012567"
**醫事機構名稱**：[OrganizationTWCM-min](Organization-OrganizationTWCM-min.md) "捷達世中醫診所"

**文件標題**：中醫門診單

**文件敏感性**：normal ( [v3 Code System Confidentiality](http://terminology.hl7.org/CodeSystem/v3-Confidentiality/)#N)

**病摘小節內容：**

> **section[PatientInformation]：**
**section[educationlevel]**： [Observation/ObservationEducationLevelTWCM-min](Observation-ObservationEducationLevelTWCM-min.md)
**section[occupation]**： [Observation/ObservationOccupationTWCM-min](Observation-ObservationOccupationTWCM-min.md)
**section[bloodtype]**： [Observation/ObservationBloodtypeTWCM-min](Observation-ObservationBloodtypeTWCM-min.md)**section[AllergyIntolerance]**： [AllergyIntolerance/AllergyIntoleranceTWCM-min](AllergyIntolerance-AllergyIntoleranceTWCM-min.md)**section[ConditionPastMedicalHistory]**： [Condition/ConditionPastMedicalHistoryTWCM-min](Condition-ConditionPastMedicalHistoryTWCM-min.md)**section[ConditionMajorIllness]**： [Observation/ObservationMajorIllnessTWCM-min](Observation-ObservationMajorIllnessTWCM-min.md)**section[Medication]**：
**section[medication]**： [Medication/MedicationTWCM-min](Medication-MedicationTWCM-min.md)
**section[medication]**： [Medication/MedicationTWCM-pro](Medication-MedicationTWCM-pro.md)
**section[medicationrequest]**： [MedicationRequest/MedicationRequestTWCM-min](MedicationRequest-MedicationRequestTWCM-min.md)
**section[medicationrequest]**： [MedicationRequest/MedicationRequestTWCM-pro](MedicationRequest-MedicationRequestTWCM-pro.md)**section[ConditionDiagnosis]**：
**section[conditiondiagnosis]**： [Condition/ConditionDiagnosisTWCM-min](Condition-ConditionDiagnosisTWCM-min.md)
**section[practitioner]**： [Practitioner/PractitionerTWCM-pro](Practitioner-PractitionerTWCM-pro.md)
**section[careplan]**： [CarePlan/CarePlanTWCM-min](CarePlan-CarePlanTWCM-min.md)
**section[observationtonguecondition]**： [Observation/ObservationTongueConditionTWCM-min](Observation-ObservationTongueConditionTWCM-min.md)
**section[observationpulsecondition]**： [Observation/ObservationPulseConditionTWCM-min](Observation-ObservationPulseConditionTWCM-min.md)
**section[observationsyndrometype]**： [Observation/ObservationSyndromeTypeTWCM-min](Observation-ObservationSyndromeTypeTWCM-min.md)
**section[observationtherapeuticprinciples]**： [Observation/ObservationTherapeuticPrinciplesTWCM-min](Observation-ObservationTherapeuticPrinciplesTWCM-min.md)
**section[ConditionChiefComplaint]**： [Condition/ConditionChiefComplaintTWCM-min](Condition-ConditionChiefComplaintTWCM-min.md)**section[ObservationVitalSign]**： [Observation/ObservationVitalSignTWCM-min](Observation-ObservationVitalSignTWCM-min.md)**section[Procedure]**： [Procedure/ProcedureTWCM-min](Procedure-ProcedureTWCM-min.md)
**section[Procedure]**： [Procedure/ProcedureTWCM-minn](Procedure-ProcedureTWCM-minn.md)
**section[Procedure]**： [Procedure/ProcedureTWCM-pro](Procedure-ProcedureTWCM-pro.md)**section[ObservationLabResults]**：
**section[observation]**： [Observation/ObservationTWCM-min](Observation-ObservationTWCM-min.md)
**section[observation]**： [Observation/ObservationTWCM-pro](Observation-ObservationTWCM-pro.md)
**section[servicerequest]**： [ServiceRequest/ServiceRequestTWCM-min](ServiceRequest-ServiceRequestTWCM-min.md)
**section[servicerequest]**： [ServiceRequest/ServiceRequestTWCM-pro](ServiceRequest-ServiceRequestTWCM-pro.md)
**section[diagnosticreport]**： [DiagnosticReport/DiagnosticReportTWCM-min](DiagnosticReport-DiagnosticReportTWCM-min.md)
**section[organizationinspection]**： [Organization/OrganizationInspectionTWCM-min](Organization-OrganizationInspectionTWCM-min.md)**section[DocumentReference]**： [DocumentReference/DocumentReferenceTWCM-min](DocumentReference-DocumentReferenceTWCM-min.md)



## Resource Content

```json
{
  "resourceType" : "Composition",
  "id" : "CompositionTWCM-min",
  "meta" : {
    "versionId" : "1",
    "profile" : ["https://www.nricm.edu.tw/twcm/StructureDefinition/composition-twcm",
    "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Composition-twcore"]
  },
  "identifier" : {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
        "code" : "SNO"
      }]
    },
    "value" : "TW.NRICM.Clinic.ChineseMedicine.1"
  },
  "status" : "final",
  "type" : {
    "coding" : [{
      "system" : "http://loinc.org",
      "code" : "34108-1",
      "display" : "Outpatient Note"
    }]
  },
  "subject" : {
    "reference" : "Patient/PatientTWCM-min"
  },
  "encounter" : {
    "reference" : "Encounter/EncounterTWCM-min"
  },
  "date" : "2010-04-21T14:30:00+08:00",
  "author" : [{
    "reference" : "Organization/OrganizationTWCM-min"
  }],
  "title" : "中醫門診單",
  "confidentiality" : "N",
  "section" : [{
    "title" : "病人資料",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "52460-3",
        "display" : "Patient Information"
      }]
    },
    "section" : [{
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "80913-7",
          "display" : "Highest level of education [US Standard Certificate of Death]"
        }]
      },
      "entry" : [{
        "reference" : "Observation/ObservationEducationLevelTWCM-min"
      }]
    },
    {
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "85658-3",
          "display" : "Occupation [Type]"
        }]
      },
      "entry" : [{
        "reference" : "Observation/ObservationOccupationTWCM-min"
      }]
    },
    {
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "882-1",
          "display" : "ABO and Rh group [Type] in Blood"
        }]
      },
      "entry" : [{
        "reference" : "Observation/ObservationBloodtypeTWCM-min"
      }]
    }]
  },
  {
    "title" : "過敏史",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "48765-2",
        "display" : "Allergies and adverse reactions Document"
      }]
    },
    "entry" : [{
      "reference" : "AllergyIntolerance/AllergyIntoleranceTWCM-min"
    }]
  },
  {
    "title" : "過去病史",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "11348-0",
        "display" : "History of Past illness note"
      }]
    },
    "entry" : [{
      "reference" : "Condition/ConditionPastMedicalHistoryTWCM-min"
    }]
  },
  {
    "title" : "重大傷病",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "11338-1",
        "display" : "History of Major illnesses and injuries Narrative"
      }]
    },
    "entry" : [{
      "reference" : "Observation/ObservationMajorIllnessTWCM-min"
    }]
  },
  {
    "title" : "用藥紀錄",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "10160-0",
        "display" : "History of Medication use Narrative"
      }]
    },
    "section" : [{
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "87232-5",
          "display" : "Medication administration.brief"
        }]
      },
      "entry" : [{
        "reference" : "Medication/MedicationTWCM-min"
      }]
    },
    {
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "87232-5",
          "display" : "Medication administration.brief"
        }]
      },
      "entry" : [{
        "reference" : "Medication/MedicationTWCM-pro"
      }]
    },
    {
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "57833-6",
          "display" : "Prescription for medication"
        }]
      },
      "entry" : [{
        "reference" : "MedicationRequest/MedicationRequestTWCM-min"
      }]
    },
    {
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "57833-6",
          "display" : "Prescription for medication"
        }]
      },
      "entry" : [{
        "reference" : "MedicationRequest/MedicationRequestTWCM-pro"
      }]
    }]
  },
  {
    "title" : "診斷",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "11450-4",
        "display" : "Problem list - Reported"
      }]
    },
    "section" : [{
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "29548-5",
          "display" : "Diagnosis Narrative"
        }]
      },
      "entry" : [{
        "reference" : "Condition/ConditionDiagnosisTWCM-min"
      }]
    },
    {
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "18600-7",
          "display" : "Primary practitioner identifier"
        }]
      },
      "entry" : [{
        "reference" : "Practitioner/PractitionerTWCM-pro"
      }]
    },
    {
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "101541-1",
          "display" : "Multidisciplinary Comprehensive plan of care note"
        }]
      },
      "entry" : [{
        "reference" : "CarePlan/CarePlanTWCM-min"
      }]
    },
    {
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "29548-5",
          "display" : "Diagnosis Narrative"
        }]
      },
      "entry" : [{
        "reference" : "Observation/ObservationTongueConditionTWCM-min"
      }]
    },
    {
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "29548-5",
          "display" : "Diagnosis Narrative"
        }]
      },
      "entry" : [{
        "reference" : "Observation/ObservationPulseConditionTWCM-min"
      }]
    },
    {
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "29548-5",
          "display" : "Diagnosis Narrative"
        }]
      },
      "entry" : [{
        "reference" : "Observation/ObservationSyndromeTypeTWCM-min"
      }]
    },
    {
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "29548-5",
          "display" : "Diagnosis Narrative"
        }]
      },
      "entry" : [{
        "reference" : "Observation/ObservationTherapeuticPrinciplesTWCM-min"
      }]
    }]
  },
  {
    "title" : "病人主訴",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "10154-3",
        "display" : "Chief complaint Narrative - Reported"
      }]
    },
    "entry" : [{
      "reference" : "Condition/ConditionChiefComplaintTWCM-min"
    }]
  },
  {
    "title" : "生命徵象",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "8716-3",
        "display" : "Vital signs note"
      }]
    },
    "entry" : [{
      "reference" : "Observation/ObservationVitalSignTWCM-min"
    }]
  },
  {
    "title" : "處置或手術",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "29554-3",
        "display" : "Procedure Narrative"
      }]
    },
    "entry" : [{
      "reference" : "Procedure/ProcedureTWCM-min"
    },
    {
      "reference" : "Procedure/ProcedureTWCM-minn"
    },
    {
      "reference" : "Procedure/ProcedureTWCM-pro"
    }]
  },
  {
    "title" : "實驗室檢驗檢查紀錄",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "30954-2",
        "display" : "Relevant diagnostic tests/laboratory data note"
      }]
    },
    "section" : [{
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "19146-0",
          "display" : "Referral lab test results"
        }]
      },
      "entry" : [{
        "reference" : "Observation/ObservationTWCM-min"
      }]
    },
    {
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "19146-0",
          "display" : "Referral lab test results"
        }]
      },
      "entry" : [{
        "reference" : "Observation/ObservationTWCM-pro"
      }]
    },
    {
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "77597-3",
          "display" : "Orders placed Document"
        }]
      },
      "entry" : [{
        "reference" : "ServiceRequest/ServiceRequestTWCM-min"
      }]
    },
    {
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "77597-3",
          "display" : "Orders placed Document"
        }]
      },
      "entry" : [{
        "reference" : "ServiceRequest/ServiceRequestTWCM-pro"
      }]
    },
    {
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "50398-7",
          "display" : "Narrative diagnostic report [Interpretation]"
        }]
      },
      "entry" : [{
        "reference" : "DiagnosticReport/DiagnosticReportTWCM-min"
      }]
    },
    {
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "52482-7",
          "display" : "Laboratory"
        }]
      },
      "entry" : [{
        "reference" : "Organization/OrganizationInspectionTWCM-min"
      }]
    }]
  },
  {
    "title" : "健康問題文件",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "75310-3",
        "display" : "Health concerns Document"
      }]
    },
    "entry" : [{
      "reference" : "DocumentReference/DocumentReferenceTWCM-min"
    }]
  }]
}

```
