診所門診病摘實作指引
1.0.1 - CI Build
診所門診病摘實作指引
1.0.1 - CI Build
This page is part of the 診所門診病摘實作指引 (v1.0.1: Releases) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
病歷表單版本：1
臨床狀態：Final (CompositionStatus#final)
種類：Outpatient Note ( LOINC#34108-1)
病人：Patient/PatientMCR-min "張睿寧"
就醫事件：Encounter/EncounterMCR-min
文件產生時間：2010-04-20T17:50:28
醫事機構代碼：OrganizationMCR-min "3214567890"
醫事機構名稱：OrganizationMCR-min "捷達世診所"
文件標題：西醫門診單
文件敏感性：normal ( v3 Code System Confidentiality#N)
病摘小節內容：
section[PatientInformation]：
section[educationlevel]： Observation/ObservationEducationLevelMCR-min
section[occupation]： Observation/ObservationOccupationMCR-min
section[bloodtype]： Observation/ObservationBloodtypeMCR-minsection[AllergyIntolerance]： Allergyintolerance/AllergyIntoleranceMCR-min
section[ConditionPastMedicalHistory]：Condition/ConditionPastMedicalHistoryMCR-min
section[ConditionMajorIllness]： Observation/ObservationMajorIllnessMCR-min
section[ConditionMajorIllness]： Condition/ConditionMajorIllnessMCR-min
section[ConditionMajorIllness]： Condition/ConditionMajorIllnessMCR-prosection[Medication]：
section[medication]： Medication/MedicationMCR-min
section[medication]： Medication/MedicationMCR-pro
section[medicationrequest]： MedicationRequest/MedicationRequestMCR-min
section[medicationrequest]： MedicationRequest/MedicationRequestMCR-prosection[ConditionDiagnosis]：
section[conditiondiagnosis]： Condition/ConditionDiagnosisMCR-min
section[practitioner]： Practitioner/PractitionerClinEMR-min
section[careplan]： CarePlan/CarePlanMCR-minsection[ConditionChiefComplaint]： Condition/ConditionChiefComplaintMCR-min
section[ObservationVitalSign]： Observation/ObservationVitalSignMCR-min
section[Procedure]： Procedure/ProcedureMCR-min
section[Procedure]： Procedure/ProcedureMCR-prosection[ObservationLabResults]：
section[observation]： Observation/ObservationMCR-min
section[observation]： Observation/ObservationMCR-pro
section[servicerequest]： ServiceRequest/ServiceRequestMCR-min
section[servicerequest]： ServiceRequest/ServiceRequestMCR-pro
section[diagnosticreport]： DiagnosticReport/DiagnosticReportMCR-min
section[organizationinspection]： Organization/OrganizationInspectionClinEMR-minsection[DocumentReference]： DocumentReference/DocumentReferenceMCR-min