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

## : 門診單架構 - TTL Representation

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    @prefix fhir: <http://hl7.org/fhir/> .
    @prefix loinc: <http://loinc.org/rdf#> .
    @prefix owl: <http://www.w3.org/2002/07/owl#> .
    @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
    @prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

    # - resource -------------------------------------------------------------------

    <http://hl7.org/fhir/Composition/CompositionTWCM-min> a fhir:Composition ;
      fhir:nodeRole fhir:treeRoot ;
      fhir:Resource.id [ fhir:value "CompositionTWCM-min"] ;
      fhir:Resource.meta [
         fhir:Meta.versionId [ fhir:value "1" ] ;
         fhir:Meta.profile [
           fhir:value "https://www.nricm.edu.tw/twcm/StructureDefinition/composition-twcm" ;
           fhir:index 0 ;
           fhir:link <https://www.nricm.edu.tw/twcm/StructureDefinition/composition-twcm>
         ], [
           fhir:value "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Composition-twcore" ;
           fhir:index 1 ;
           fhir:link <https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Composition-twcore>
         ]
      ] ;
      fhir:DomainResource.text [
         fhir:Narrative.status [ fhir:value "generated" ] ;
         fhir:Narrative.div "<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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         fhir:Identifier.value [ fhir:value "TW.NRICM.Clinic.ChineseMedicine.1" ]
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           fhir:Coding.code [ fhir:value "34108-1" ] ;
           fhir:Coding.display [ fhir:value "Outpatient Note" ]
         ]
      ] ;
      fhir:Composition.subject [
         fhir:link <http://hl7.org/fhir/Patient/PatientTWCM-min> ;
         fhir:Reference.reference [ fhir:value "Patient/PatientTWCM-min" ]
      ] ;
      fhir:Composition.encounter [
         fhir:link <http://hl7.org/fhir/Encounter/EncounterTWCM-min> ;
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      ] ;
      fhir:Composition.date [ fhir:value "2010-04-21T14:30:00+08:00"^^xsd:dateTime] ;
      fhir:Composition.author [
         fhir:index 0 ;
         fhir:link <http://hl7.org/fhir/Organization/OrganizationTWCM-min> ;
         fhir:Reference.reference [ fhir:value "Organization/OrganizationTWCM-min" ]
      ] ;
      fhir:Composition.title [ fhir:value "中醫門診單"] ;
      fhir:Composition.confidentiality [ fhir:value "N"] ;
      fhir:Composition.section [
         fhir:index 0 ;
         fhir:Composition.section.title [ fhir:value "病人資料" ] ;
         fhir:Composition.section.code [
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             fhir:Coding.code [ fhir:value "52460-3" ] ;
             fhir:Coding.display [ fhir:value "Patient Information" ]
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         fhir:Composition.section.section [
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               fhir:Coding.code [ fhir:value "85658-3" ] ;
               fhir:Coding.display [ fhir:value "Occupation [Type]" ]
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           fhir:Composition.section.entry [
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               fhir:Coding.code [ fhir:value "882-1" ] ;
               fhir:Coding.display [ fhir:value "ABO and Rh group [Type] in Blood" ]
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             fhir:link <http://hl7.org/fhir/Observation/ObservationBloodtypeTWCM-min> ;
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         fhir:Composition.section.title [ fhir:value "過敏史" ] ;
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             fhir:Coding.display [ fhir:value "Allergies and adverse reactions Document" ]
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         fhir:Composition.section.title [ fhir:value "過去病史" ] ;
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         fhir:Composition.section.title [ fhir:value "重大傷病" ] ;
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             fhir:Coding.code [ fhir:value "11338-1" ] ;
             fhir:Coding.display [ fhir:value "History of Major illnesses and injuries Narrative" ]
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           fhir:link <http://hl7.org/fhir/Observation/ObservationMajorIllnessTWCM-min> ;
           fhir:Reference.reference [ fhir:value "Observation/ObservationMajorIllnessTWCM-min" ]
         ]
      ], [
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         fhir:Composition.section.title [ fhir:value "用藥紀錄" ] ;
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             fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
             fhir:Coding.code [ fhir:value "10160-0" ] ;
             fhir:Coding.display [ fhir:value "History of Medication use Narrative" ]
           ]
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           fhir:Composition.section.entry [
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             fhir:Reference.reference [ fhir:value "Medication/MedicationTWCM-min" ]
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               fhir:Coding.display [ fhir:value "Diagnosis Narrative" ]
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           fhir:Composition.section.entry [
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               fhir:Coding.display [ fhir:value "Diagnosis Narrative" ]
             ]
           ] ;
           fhir:Composition.section.entry [
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             fhir:link <http://hl7.org/fhir/Observation/ObservationTherapeuticPrinciplesTWCM-min> ;
             fhir:Reference.reference [ fhir:value "Observation/ObservationTherapeuticPrinciplesTWCM-min" ]
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      ], [
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         fhir:Composition.section.title [ fhir:value "病人主訴" ] ;
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         ]
      ], [
         fhir:index 7 ;
         fhir:Composition.section.title [ fhir:value "生命徵象" ] ;
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             a loinc:8716-3 ;
             fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
             fhir:Coding.code [ fhir:value "8716-3" ] ;
             fhir:Coding.display [ fhir:value "Vital signs note" ]
           ]
         ] ;
         fhir:Composition.section.entry [
           fhir:index 0 ;
           fhir:link <http://hl7.org/fhir/Observation/ObservationVitalSignTWCM-min> ;
           fhir:Reference.reference [ fhir:value "Observation/ObservationVitalSignTWCM-min" ]
         ]
      ], [
         fhir:index 8 ;
         fhir:Composition.section.title [ fhir:value "處置或手術" ] ;
         fhir:Composition.section.code [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             a loinc:29554-3 ;
             fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
             fhir:Coding.code [ fhir:value "29554-3" ] ;
             fhir:Coding.display [ fhir:value "Procedure Narrative" ]
           ]
         ] ;
         fhir:Composition.section.entry [
           fhir:index 0 ;
           fhir:link <http://hl7.org/fhir/Procedure/ProcedureTWCM-min> ;
           fhir:Reference.reference [ fhir:value "Procedure/ProcedureTWCM-min" ]
         ], [
           fhir:index 1 ;
           fhir:link <http://hl7.org/fhir/Procedure/ProcedureTWCM-minn> ;
           fhir:Reference.reference [ fhir:value "Procedure/ProcedureTWCM-minn" ]
         ], [
           fhir:index 2 ;
           fhir:link <http://hl7.org/fhir/Procedure/ProcedureTWCM-pro> ;
           fhir:Reference.reference [ fhir:value "Procedure/ProcedureTWCM-pro" ]
         ]
      ], [
         fhir:index 9 ;
         fhir:Composition.section.title [ fhir:value "實驗室檢驗檢查紀錄" ] ;
         fhir:Composition.section.code [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             a loinc:30954-2 ;
             fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
             fhir:Coding.code [ fhir:value "30954-2" ] ;
             fhir:Coding.display [ fhir:value "Relevant diagnostic tests/laboratory data note" ]
           ]
         ] ;
         fhir:Composition.section.section [
           fhir:index 0 ;
           fhir:Composition.section.code [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               a loinc:19146-0 ;
               fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
               fhir:Coding.code [ fhir:value "19146-0" ] ;
               fhir:Coding.display [ fhir:value "Referral lab test results" ]
             ]
           ] ;
           fhir:Composition.section.entry [
             fhir:index 0 ;
             fhir:link <http://hl7.org/fhir/Observation/ObservationTWCM-min> ;
             fhir:Reference.reference [ fhir:value "Observation/ObservationTWCM-min" ]
           ]
         ], [
           fhir:index 1 ;
           fhir:Composition.section.code [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               a loinc:19146-0 ;
               fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
               fhir:Coding.code [ fhir:value "19146-0" ] ;
               fhir:Coding.display [ fhir:value "Referral lab test results" ]
             ]
           ] ;
           fhir:Composition.section.entry [
             fhir:index 0 ;
             fhir:link <http://hl7.org/fhir/Observation/ObservationTWCM-pro> ;
             fhir:Reference.reference [ fhir:value "Observation/ObservationTWCM-pro" ]
           ]
         ], [
           fhir:index 2 ;
           fhir:Composition.section.code [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               a loinc:77597-3 ;
               fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
               fhir:Coding.code [ fhir:value "77597-3" ] ;
               fhir:Coding.display [ fhir:value "Orders placed Document" ]
             ]
           ] ;
           fhir:Composition.section.entry [
             fhir:index 0 ;
             fhir:link <http://hl7.org/fhir/ServiceRequest/ServiceRequestTWCM-min> ;
             fhir:Reference.reference [ fhir:value "ServiceRequest/ServiceRequestTWCM-min" ]
           ]
         ], [
           fhir:index 3 ;
           fhir:Composition.section.code [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               a loinc:77597-3 ;
               fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
               fhir:Coding.code [ fhir:value "77597-3" ] ;
               fhir:Coding.display [ fhir:value "Orders placed Document" ]
             ]
           ] ;
           fhir:Composition.section.entry [
             fhir:index 0 ;
             fhir:link <http://hl7.org/fhir/ServiceRequest/ServiceRequestTWCM-pro> ;
             fhir:Reference.reference [ fhir:value "ServiceRequest/ServiceRequestTWCM-pro" ]
           ]
         ], [
           fhir:index 4 ;
           fhir:Composition.section.code [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               a loinc:50398-7 ;
               fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
               fhir:Coding.code [ fhir:value "50398-7" ] ;
               fhir:Coding.display [ fhir:value "Narrative diagnostic report [Interpretation]" ]
             ]
           ] ;
           fhir:Composition.section.entry [
             fhir:index 0 ;
             fhir:link <http://hl7.org/fhir/DiagnosticReport/DiagnosticReportTWCM-min> ;
             fhir:Reference.reference [ fhir:value "DiagnosticReport/DiagnosticReportTWCM-min" ]
           ]
         ], [
           fhir:index 5 ;
           fhir:Composition.section.code [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               a loinc:52482-7 ;
               fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
               fhir:Coding.code [ fhir:value "52482-7" ] ;
               fhir:Coding.display [ fhir:value "Laboratory" ]
             ]
           ] ;
           fhir:Composition.section.entry [
             fhir:index 0 ;
             fhir:link <http://hl7.org/fhir/Organization/OrganizationInspectionTWCM-min> ;
             fhir:Reference.reference [ fhir:value "Organization/OrganizationInspectionTWCM-min" ]
           ]
         ]
      ], [
         fhir:index 10 ;
         fhir:Composition.section.title [ fhir:value "健康問題文件" ] ;
         fhir:Composition.section.code [
           fhir:CodeableConcept.coding [
             fhir:index 0 ;
             a loinc:75310-3 ;
             fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
             fhir:Coding.code [ fhir:value "75310-3" ] ;
             fhir:Coding.display [ fhir:value "Health concerns Document" ]
           ]
         ] ;
         fhir:Composition.section.entry [
           fhir:index 0 ;
           fhir:link <http://hl7.org/fhir/DocumentReference/DocumentReferenceTWCM-min> ;
           fhir:Reference.reference [ fhir:value "DocumentReference/DocumentReferenceTWCM-min" ]
         ]
      ] .

    <http://hl7.org/fhir/Patient/PatientTWCM-min> a fhir:Patient .

    <http://hl7.org/fhir/Encounter/EncounterTWCM-min> a fhir:Encounter .

    <http://hl7.org/fhir/Organization/OrganizationTWCM-min> a fhir:Organization .

    <http://hl7.org/fhir/Observation/ObservationEducationLevelTWCM-min> a fhir:Observation .

    <http://hl7.org/fhir/Observation/ObservationOccupationTWCM-min> a fhir:Observation .

    <http://hl7.org/fhir/Observation/ObservationBloodtypeTWCM-min> a fhir:Observation .

    <http://hl7.org/fhir/AllergyIntolerance/AllergyIntoleranceTWCM-min> a fhir:AllergyIntolerance .

    <http://hl7.org/fhir/Condition/ConditionPastMedicalHistoryTWCM-min> a fhir:Condition .

    <http://hl7.org/fhir/Observation/ObservationMajorIllnessTWCM-min> a fhir:Observation .

    <http://hl7.org/fhir/Medication/MedicationTWCM-min> a fhir:Medication .

    <http://hl7.org/fhir/Medication/MedicationTWCM-pro> a fhir:Medication .

    <http://hl7.org/fhir/MedicationRequest/MedicationRequestTWCM-min> a fhir:MedicationRequest .

    <http://hl7.org/fhir/MedicationRequest/MedicationRequestTWCM-pro> a fhir:MedicationRequest .

    <http://hl7.org/fhir/Condition/ConditionDiagnosisTWCM-min> a fhir:Condition .

    <http://hl7.org/fhir/Practitioner/PractitionerTWCM-pro> a fhir:Practitioner .

    <http://hl7.org/fhir/CarePlan/CarePlanTWCM-min> a fhir:CarePlan .

    <http://hl7.org/fhir/Observation/ObservationTongueConditionTWCM-min> a fhir:Observation .

    <http://hl7.org/fhir/Observation/ObservationPulseConditionTWCM-min> a fhir:Observation .

    <http://hl7.org/fhir/Observation/ObservationSyndromeTypeTWCM-min> a fhir:Observation .

    <http://hl7.org/fhir/Observation/ObservationTherapeuticPrinciplesTWCM-min> a fhir:Observation .

    <http://hl7.org/fhir/Condition/ConditionChiefComplaintTWCM-min> a fhir:Condition .

    <http://hl7.org/fhir/Observation/ObservationVitalSignTWCM-min> a fhir:Observation .

    <http://hl7.org/fhir/Procedure/ProcedureTWCM-min> a fhir:Procedure .

    <http://hl7.org/fhir/Procedure/ProcedureTWCM-minn> a fhir:Procedure .

    <http://hl7.org/fhir/Procedure/ProcedureTWCM-pro> a fhir:Procedure .

    <http://hl7.org/fhir/Observation/ObservationTWCM-min> a fhir:Observation .

    <http://hl7.org/fhir/Observation/ObservationTWCM-pro> a fhir:Observation .

    <http://hl7.org/fhir/ServiceRequest/ServiceRequestTWCM-min> a fhir:ServiceRequest .

    <http://hl7.org/fhir/ServiceRequest/ServiceRequestTWCM-pro> a fhir:ServiceRequest .

    <http://hl7.org/fhir/DiagnosticReport/DiagnosticReportTWCM-min> a fhir:DiagnosticReport .

    <http://hl7.org/fhir/Organization/OrganizationInspectionTWCM-min> a fhir:Organization .

    <http://hl7.org/fhir/DocumentReference/DocumentReferenceTWCM-min> a fhir:DocumentReference .

    # - ontology header ------------------------------------------------------------

    <http://hl7.org/fhir/Composition/CompositionTWCM-min.ttl> a owl:Ontology ;
      owl:imports fhir:fhir.ttl ;
      owl:versionIRI <http://build.fhir.org/Composition/CompositionTWCM-min.ttl> .