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

: 在宅急症結案摘要範例 - XML Representation

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<Composition xmlns="http://hl7.org/fhir">
  <id value="hah-summary"/>
  <meta>
    <profile
             value="http://ltc-ig.fhir.tw/StructureDefinition/HAHCompositionSummary"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Composition hah-summary</b></p><a name="hah-summary"> </a><a name="hchah-summary"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-HAHCompositionSummary.html">在宅急症-結案與轉銜摘要</a></p></div><p><b>status</b>: Final</p><p><b>type</b>: <span title="Codes:{http://ltc-ig.fhir.tw/CodeSystem/hah-document discharge-summary}, {http://loinc.org 18842-5}">Discharge summary</span></p><p><b>encounter</b>: <a href="Encounter-hah-admission.html">Encounter: status = finished; class = inpatient encounter (ActCode#IMP); type = 在宅急症照護; period = 2026-09-01 09:00:00+0800 --&gt; 2026-09-05 12:00:00+0800</a></p><p><b>date</b>: 2026-09-05 12:00:00+0800</p><p><b>author</b>: <a href="Practitioner-hah-practitioner.html">Practitioner 李示範</a></p><p><b>title</b>: 王測試在宅急症結案摘要</p><p><b>custodian</b>: <a href="Organization-hah-organization.html">Organization 在宅急症示範醫療機構</a></p></div>
  </text>
  <status value="final"/>
  <type>
    <coding>
      <system value="http://ltc-ig.fhir.tw/CodeSystem/hah-document"/>
      <code value="discharge-summary"/>
    </coding>
    <coding>
      <system value="http://loinc.org"/>
      <code value="18842-5"/>
      <display value="Discharge summary"/>
    </coding>
  </type>
  <subject>🔗 
    <reference value="Patient/hah-patient"/>
  </subject>
  <encounter>🔗 
    <reference value="Encounter/hah-admission"/>
  </encounter>
  <date value="2026-09-05T12:00:00+08:00"/>
  <author>🔗 
    <reference value="Practitioner/hah-practitioner"/>
  </author>
  <title value="王測試在宅急症結案摘要"/>
  <custodian>🔗 
    <reference value="Organization/hah-organization"/>
  </custodian>
  <section>
    <title value="療程經過"/>
    <code>
      <coding>
        <system value="http://ltc-ig.fhir.tw/CodeSystem/hah-document"/>
        <code value="course"/>
      </coding>
    </code>
    <text>
      <status value="additional"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><p>本次在宅照護完成;包含實地與視訊訪視。</p></div>
    </text>
    <entry>🔗 
      <reference value="EpisodeOfCare/hah-episode"/>
    </entry>
    <entry>🔗 
      <reference value="Encounter/hah-admission"/>
    </entry>
    <entry>🔗 
      <reference value="Encounter/hah-visit"/>
    </entry>
    <entry>🔗 
      <reference value="Encounter/hah-video-visit"/>
    </entry>
    <entry>🔗 
      <reference value="ClinicalImpression/hah-impression"/>
    </entry>
    <entry>🔗 
      <reference value="QuestionnaireResponse/hah-assessment"/>
    </entry>
  </section>
  <section>
    <title value="診斷與問題"/>
    <code>
      <coding>
        <system value="http://ltc-ig.fhir.tw/CodeSystem/hah-document"/>
        <code value="problems"/>
      </coding>
    </code>
    <text>
      <status value="additional"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><p>呼吸道感染,療程結束時已解除。</p></div>
    </text>
    <entry>🔗 
      <reference value="Condition/hah-condition"/>
    </entry>
  </section>
  <section>
    <title value="過敏資訊"/>
    <code>
      <coding>
        <system value="http://ltc-ig.fhir.tw/CodeSystem/hah-document"/>
        <code value="allergies"/>
      </coding>
    </code>
    <text>
      <status value="additional"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><p>已記錄青黴素過敏及皮疹反應。</p></div>
    </text>
    <entry>🔗 
      <reference value="AllergyIntolerance/hah-allergy"/>
    </entry>
  </section>
  <section>
    <title value="藥物與給藥"/>
    <code>
      <coding>
        <system value="http://ltc-ig.fhir.tw/CodeSystem/hah-document"/>
        <code value="medications"/>
      </coding>
    </code>
    <text>
      <status value="additional"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><p>示範輸注與取消給藥;不是臨床處方建議。</p></div>
    </text>
    <entry>🔗 
      <reference value="MedicationRequest/hah-medication-order"/>
    </entry>
    <entry>🔗 
      <reference value="MedicationAdministration/hah-infusion"/>
    </entry>
    <entry>🔗 
      <reference value="MedicationAdministration/hah-medication-not-done"/>
    </entry>
  </section>
  <section>
    <title value="檢查結果"/>
    <code>
      <coding>
        <system value="http://ltc-ig.fhir.tw/CodeSystem/hah-document"/>
        <code value="results"/>
      </coding>
    </code>
    <text>
      <status value="additional"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><p>附體溫與血糖檢驗。</p></div>
    </text>
    <entry>🔗 
      <reference value="Observation/hah-temperature"/>
    </entry>
    <entry>🔗 
      <reference value="DiagnosticReport/hah-report"/>
    </entry>
  </section>
  <section>
    <title value="照護計畫與措施"/>
    <code>
      <coding>
        <system value="http://ltc-ig.fhir.tw/CodeSystem/hah-document"/>
        <code value="care"/>
      </coding>
    </code>
    <text>
      <status value="additional"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><p>附照護目標、計畫、衛教、同意及設備。</p></div>
    </text>
    <entry>🔗 
      <reference value="CarePlan/hah-plan"/>
    </entry>
    <entry>🔗 
      <reference value="Goal/hah-goal"/>
    </entry>
    <entry>🔗 
      <reference value="Procedure/hah-procedure"/>
    </entry>
    <entry>🔗 
      <reference value="Consent/hah-consent"/>
    </entry>
    <entry>🔗 
      <reference value="Device/hah-device"/>
    </entry>
  </section>
  <section>
    <title value="後續照護與交班"/>
    <code>
      <coding>
        <system value="http://ltc-ig.fhir.tw/CodeSystem/hah-document"/>
        <code value="follow-up"/>
      </coding>
    </code>
    <text>
      <status value="additional"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><p>已完成本次會診與檢驗工作;後續回診資訊尚未提供。</p></div>
    </text>
    <entry>🔗 
      <reference value="ServiceRequest/hah-consult-request"/>
    </entry>
    <entry>🔗 
      <reference value="ServiceRequest/hah-lab-request"/>
    </entry>
    <entry>🔗 
      <reference value="Task/hah-task"/>
    </entry>
    <entry>🔗 
      <reference value="Communication/hah-communication"/>
    </entry>
    <entry>🔗 
      <reference value="DocumentReference/hah-attachment"/>
    </entry>
  </section>
</Composition>