臺灣長期照顧實作指引(TW LTC IG)
1.1.0 - STU 1.1.0

臺灣長期照顧實作指引(TW LTC IG) - Local Development build (v1.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

: 居家護理照護計畫範例 - XML Representation

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<CarePlan xmlns="http://hl7.org/fhir">
  <id value="hn-careplan-example"/>
  <meta>
    <profile value="http://ltc-ig.fhir.tw/StructureDefinition/HNCarePlan"/>
  </meta>
  <text>
    <status value="additional"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p>陳明慧的居家護理照護計畫：降低跌倒風險。原措施為每日檢查走道障礙物，已停止並改採個別移位協助措施。照護者應依護理人員指導執行。</p></div>
  </text>
  <extension url="http://ltc-ig.fhir.tw/StructureDefinition/ExtHNEpisode">
    <valueReference>🔗 
      <reference value="EpisodeOfCare/hn-episode-example"/>
    </valueReference>
  </extension>
  <extension url="http://ltc-ig.fhir.tw/StructureDefinition/ExtHNSourceForm">
    <valueReference>🔗 
      <reference value="QuestionnaireResponse/hn-targets-example"/>
    </valueReference>
  </extension>
  <extension url="http://ltc-ig.fhir.tw/StructureDefinition/ExtHNSourceForm">
    <valueReference>🔗 
      <reference value="QuestionnaireResponse/hn-measures-example"/>
    </valueReference>
  </extension>
  <status value="active"/>
  <intent value="plan"/>
  <category>
    <coding>
      <system
              value="https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/careplan-category-tw"/>
      <code value="assess-plan"/>
    </coding>
  </category>
  <subject>🔗 
    <reference value="Patient/hn-patient-example"/>
  </subject>
  <period>
    <start value="2025-12-08"/>
  </period>
  <author>🔗 
    <reference value="Practitioner/hn-nurse-example"/>
  </author>
  <supportingInfo>🔗 
    <reference value="QuestionnaireResponse/hn-casesummary-example"/>
  </supportingInfo>
  <goal>🔗 
    <reference value="Goal/hn-goal-example"/>
  </goal>
  <activity>
    <extension
               url="http://ltc-ig.fhir.tw/StructureDefinition/ExtHNMeasureStop">
      <extension url="date">
        <valueDate value="2025-12-09"/>
      </extension>
      <extension url="reason">
        <valueString value="改採個別移位協助措施"/>
      </extension>
      <extension url="nurse">
        <valueReference>🔗 
          <reference value="Practitioner/hn-nurse-example"/>
        </valueReference>
      </extension>
    </extension>
    <outcomeReference>🔗 
      <reference value="QuestionnaireResponse/hn-evaluations-example"/>
    </outcomeReference>
    <detail>
      <goal>🔗 
        <reference value="Goal/hn-goal-example"/>
      </goal>
      <status value="stopped"/>
      <scheduledPeriod>
        <start value="2025-12-08"/>
      </scheduledPeriod>
      <description value="每日檢查走道障礙物"/>
    </detail>
  </activity>
</CarePlan>