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
本頁為在宅急症的專用來源欄位與 FHIR 對照表。
| 模型欄位 | 基數 | 型態 | 內容 | FHIR 對應 | 來源與差異 |
|---|---|---|---|---|---|
patient |
1..1 | BackboneElement |
個案 | HAHPatient |
patient.js |
patient.identifier |
1..* | Identifier |
個案識別碼 | Patient.identifier |
patient.js |
patient.name |
1..2 | HumanName |
姓名 | Patient.name |
patient.js |
patient.birthDate |
1..1 | date |
出生日期 | Patient.birthDate |
patient.js |
patient.gender |
0..1 | code |
性別 | Patient.gender |
patient.js |
patient.address |
1..2 | Address |
居住地址 | Patient.address |
patient.js |
patient.telecom |
1..* | ContactPoint |
聯絡方式 | Patient.telecom |
patient.js |
patient.contact |
1..* | BackboneElement |
緊急聯絡人 | Patient.contact |
patient.js |
patient.contact.name |
1..1 | HumanName |
聯絡人姓名 | Patient.contact.name |
patient.js |
patient.contact.relationship |
1..1 | CodeableConcept |
與個案關係 | Patient.contact.relationship |
patient.js |
patient.contact.telecom |
1..* | ContactPoint |
聯絡人電話 | Patient.contact.telecom |
patient.js |
patient.caregiver |
0..* | Reference(LTCRelatedPerson) |
主要照顧者 | RelatedPerson.patient |
patient.js 的 caregiver；結構化參照為新增 |
patient.deceased |
0..1 | dateTime |
死亡時間 | Patient.deceasedDateTime |
新增死亡時間 |
intake |
0..1 | BackboneElement |
收案評估 | HAHAssessmentResponse |
新增結構化表單 |
intake.criteria |
1..1 | string |
計畫名稱與版本 | QuestionnaireResponse.item[criteria] |
新增 |
intake.homeSafety |
1..1 | string |
環境與設備可行性 | QuestionnaireResponse.item[homeSafety] |
新增 |
intake.caregiverSupport |
1..1 | string |
照顧者支援能力 | QuestionnaireResponse.item[caregiverSupport] |
新增 |
intake.decision |
1..1 | Coding |
收案建議 | QuestionnaireResponse.item[decision] |
新增 |
intake.reason |
0..1 | string |
評估原因 | QuestionnaireResponse.item[reason] |
新增 |
intake.assessor |
1..1 | Reference(LTCPractitionerRole or LTCPractitioner) |
評估人員 | QuestionnaireResponse.author |
新增 |
intake.date |
1..1 | dateTime |
評估時間 | QuestionnaireResponse.authored |
新增 |
episode |
1..1 | BackboneElement |
一次收案療程 | HAHEpisodeOfCare |
由 Patient 收案資訊與 Encounter 彙整 |
episode.identifier |
1..* | Identifier |
療程識別碼 | EpisodeOfCare.identifier |
新增穩定識別 |
episode.status |
1..1 | code |
療程狀態 | EpisodeOfCare.status |
收案、結案狀態轉換 |
episode.period |
1..1 | Period |
實際照護期間 | EpisodeOfCare.period |
收案與結案日期 |
episode.organization |
1..1 | Reference(LTCOrganization) |
負責機構 | EpisodeOfCare.managingOrganization |
patient.js、encounter.js |
episode.diagnosis |
0..* | Reference(HAHCondition) |
收案診斷 | EpisodeOfCare.diagnosis.condition |
condition.js |
episode.team |
0..* | Reference(HAHCareTeam) |
照護團隊 | EpisodeOfCare.team |
careTeam.js |
episode.referral |
0..* | Reference(HAHServiceRequest) |
收案轉介 | EpisodeOfCare.referralRequest |
新增轉介串聯 |
episode.outcome |
0..1 | CodeableConcept |
結束原因 | EpisodeOfCare.extension[outcome] |
EnrollmentInfo.vue；原因代碼需轉換 |
encounter |
1..* | BackboneElement |
整段照護或單次訪視 | HAHEncounter |
encounter.js |
encounter.identifier |
0..* | Identifier |
就診識別碼 | Encounter.identifier |
新增交換識別 |
encounter.status |
1..1 | code |
就診狀態 | Encounter.status |
encounter.js |
encounter.class |
1..1 | Coding |
照護分類 | Encounter.class |
IMP、HH；VR 為明確化 |
encounter.period |
1..1 | Period |
實際服務起訖 | Encounter.period |
encounter.js |
encounter.parent |
0..1 | Reference(HAHAdmissionEncounter) |
所屬整段照護 | Encounter.partOf |
新增；單次訪視必填 |
encounter.mode |
0..1 | code |
訪視方式 | Encounter.extension[mode] |
新增；單次訪視必填 |
encounter.participant |
1..* | Reference(LTCPractitioner or LTCPractitionerRole) |
照護人員 | Encounter.participant.individual |
encounter.js |
encounter.organization |
1..1 | Reference(LTCOrganization) |
服務機構 | Encounter.serviceProvider |
encounter.js |
encounter.location |
0..* | Reference(Location) |
照護地點 | Encounter.location.location |
task.js 的地點與座標 |
encounter.disposition |
0..1 | CodeableConcept |
出院或轉出處置 | Encounter.hospitalization.dischargeDisposition |
新增結構化資料 |
encounter.destination |
0..1 | Reference(Organization or Location) |
接續照護地點 | Encounter.hospitalization.destination |
clinicalNote.js 的 transferHospital |
problem |
0..* | BackboneElement |
診斷與照護問題 | HAHCondition |
condition.js |
problem.code |
1..1 | CodeableConcept |
診斷或問題 | Condition.code |
condition.js |
problem.category |
1..1 | CodeableConcept |
診斷或問題分類 | Condition.category |
condition.js |
problem.onset |
0..1 | dateTime |
發病時間 | Condition.onsetDateTime |
condition.js |
problem.clinicalStatus |
0..1 | CodeableConcept |
病情狀態 | Condition.clinicalStatus |
condition.js |
problem.verification |
0..1 | CodeableConcept |
確認狀態 | Condition.verificationStatus |
condition.js |
problem.encounter |
1..1 | Reference(HAHEncounter) |
對應就診 | Condition.encounter |
condition.js |
team |
0..* | BackboneElement |
團隊成員 | HAHCareTeam |
careTeam.js |
team.member |
1..1 | Reference(Practitioner or PractitionerRole or Organization or RelatedPerson) |
人員或機構 | CareTeam.participant.member |
careTeam.js |
team.role |
1..1 | CodeableConcept |
成員角色 | CareTeam.participant.role |
careTeam.js |
team.period |
0..1 | Period |
責任期間 | CareTeam.participant.period |
新增期間約定 |
plan |
0..* | BackboneElement |
照護計畫 | HAHCarePlan |
goal.js |
plan.status |
1..1 | code |
計畫狀態 | CarePlan.status |
goal.js |
plan.period |
0..1 | Period |
計畫期間 | CarePlan.period |
goal.js |
plan.problem |
0..* | Reference(HAHCondition) |
處理的問題 | CarePlan.addresses |
需求語意校正 |
plan.goal |
0..* | Reference(HAHGoal) |
預期目標 | CarePlan.goal |
goal.js |
plan.activity |
1..* | Reference(HAHServiceRequest or HAHMedicationRequest) |
預定服務或處方 | CarePlan.activity.reference；也可用 detail |
goal.js 的 activity 結構化 |
goal |
0..* | BackboneElement |
照護目標 | HAHGoal |
goal.js |
goal.description |
1..1 | CodeableConcept |
預期結果 | Goal.description |
目標與需求分開 |
goal.status |
1..1 | code |
目標狀態 | Goal.lifecycleStatus |
goal.js |
goal.due |
1..1 | date |
預期達到日期 | Goal.target.dueDate |
goal.js |
goal.result |
0..* | Reference(Observation) |
評值結果 | Goal.outcomeReference |
新增結果串聯 |
request |
0..* | BackboneElement |
服務請求 | HAHServiceRequest |
queryNote.js；檢驗及轉介串聯新增 |
request.code |
1..1 | CodeableConcept |
服務項目 | ServiceRequest.code |
原本僅部分文字，新增標準化 |
request.category |
1..* | CodeableConcept |
服務分類 | ServiceRequest.category |
新增 |
request.status |
1..1 | code |
請求狀態 | ServiceRequest.status |
queryNote.js |
request.intent |
1..1 | code |
請求意圖 | ServiceRequest.intent |
queryNote.js |
request.requester |
1..1 | Reference(Practitioner or PractitionerRole or Organization) |
開立者 | ServiceRequest.requester |
queryNote.js |
request.performer |
0..* | Reference(Practitioner or PractitionerRole or Organization) |
執行對象 | ServiceRequest.performer |
queryNote.js |
request.occurrence |
0..1 | Period |
預定服務期間 | ServiceRequest.occurrencePeriod |
新增 |
observation |
0..* | BackboneElement |
生命徵象與檢驗 | 既有量測 Profiles、HAHObservationLab |
CreateNursingNote.vue、PatientLabReports.vue |
observation.code |
1..1 | CodeableConcept |
量測或檢驗項目 | Observation.code |
體溫、心率、呼吸、血壓、血氧、血糖、CRP、血氣等 |
observation.status |
1..1 | code |
結果狀態 | Observation.status |
Observation 寫入流程 |
observation.time |
1..1 | dateTime |
量測或採檢時間 | Observation.effectiveDateTime |
既有資料 |
observation.value |
0..1 | Quantity |
數值與單位 | Observation.valueQuantity |
既有數值；須確認 UCUM |
observation.textValue |
0..1 | string |
文字結果 | Observation.valueString |
檢驗頁既有資料 |
observation.absentReason |
0..1 | CodeableConcept |
缺值原因 | Observation.dataAbsentReason |
新增缺值規則 |
observation.component |
0..* | BackboneElement |
同次量測組成值 | Observation.component |
血壓專用；單項檢驗不使用 |
observation.component.code |
1..1 | CodeableConcept |
組成項目 | Observation.component.code |
收縮壓或舒張壓 |
observation.component.value |
1..1 | Quantity |
組成數值 | Observation.component.valueQuantity |
血壓數值與 mm[Hg] |
observation.device |
0..1 | Reference(HAHDevice) |
量測設備 | Observation.device |
Device.js |
observation.encounter |
0..1 | Reference(HAHEncounter) |
量測對應就診 | Observation.encounter |
修正 focus 作外鍵的用法 |
observation.specimen |
0..1 | Reference(Specimen) |
檢體 | Observation.specimen |
新增 |
observation.referenceRange |
0..* | Range |
參考區間 | Observation.referenceRange.low/high |
PatientLabReports.vue |
report |
0..* | BackboneElement |
檢驗報告 | HAHDiagnosticReport |
新增報告層 |
report.identifier |
0..* | Identifier |
報告識別碼 | DiagnosticReport.identifier |
新增 |
report.code |
1..1 | CodeableConcept |
報告種類 | DiagnosticReport.code |
新增 |
report.status |
1..1 | code |
報告狀態 | DiagnosticReport.status |
新增 |
report.result |
1..* | Reference(HAHObservationLab) |
單項結果 | DiagnosticReport.result |
連結既有結果 |
report.specimen |
0..* | Reference(Specimen) |
檢體 | DiagnosticReport.specimen |
新增 |
report.issued |
1..1 | instant |
報告發布時間 | DiagnosticReport.issued |
新增 |
medicationOrder |
0..* | BackboneElement |
給藥處方 | HAHMedicationRequest |
新增結構化處方 |
medicationOrder.medication |
1..1 | CodeableConcept |
藥品 | MedicationRequest.medicationCodeableConcept 或 medicationReference |
新增 |
medicationOrder.status |
1..1 | code |
處方狀態 | MedicationRequest.status |
新增 |
medicationOrder.intent |
1..1 | code |
處方意圖 | MedicationRequest.intent |
新增 |
medicationOrder.dosage |
1..* | Dosage |
劑量頻率與途徑 | MedicationRequest.dosageInstruction |
新增 |
medicationOrder.requester |
1..1 | Reference(Practitioner or PractitionerRole) |
開立者 | MedicationRequest.requester |
新增 |
administration |
0..* | BackboneElement |
實際給藥 | HAHMedicationAdministration |
新增 |
administration.request |
1..1 | Reference(HAHMedicationRequest) |
對應處方 | MedicationAdministration.request |
新增 |
administration.status |
1..1 | code |
給藥狀態 | MedicationAdministration.status |
新增 |
administration.reason |
0..* | CodeableConcept |
未給藥或停止原因 | MedicationAdministration.statusReason |
新增 |
administration.time |
0..1 | dateTime |
單次給藥時間 | MedicationAdministration.effectiveDateTime |
新增；與期間擇一 |
administration.period |
0..1 | Period |
輸注期間 | MedicationAdministration.effectivePeriod |
新增；與時間點擇一 |
administration.dose |
0..1 | Quantity |
給藥劑量 | MedicationAdministration.dosage.dose |
新增 |
administration.rate |
0..1 | Quantity |
給藥速率 | MedicationAdministration.dosage.rateQuantity |
新增 |
administration.route |
0..1 | CodeableConcept |
給藥途徑 | MedicationAdministration.dosage.route |
新增 |
assessment |
0..* | BackboneElement |
臨床評估 | HAHClinicalImpression |
clinicalNote.js |
assessment.summary |
1..1 | string |
評估摘要 | ClinicalImpression.summary |
原 description、SOAP 文字 |
assessment.assessor |
1..1 | Reference(Practitioner or PractitionerRole) |
評估人員 | ClinicalImpression.assessor |
clinicalNote.js |
assessment.time |
1..1 | dateTime |
評估時間 | ClinicalImpression.effectiveDateTime |
原服務時間 |
assessment.support |
0..* | Reference(Resource) |
支持證據 | ClinicalImpression.supportingInfo |
Observation、附件等 |
procedure |
0..* | BackboneElement |
已執行處置 | HAHProcedure |
原護理措施文字；結構化新增 |
procedure.code |
1..1 | CodeableConcept |
處置項目 | Procedure.code |
原 selectedInterventions |
procedure.status |
1..1 | code |
處置狀態 | Procedure.status |
新增 |
procedure.period |
0..1 | Period |
執行期間 | Procedure.performedPeriod |
新增；也可用 performedDateTime |
procedure.performer |
1..* | Reference(Practitioner or PractitionerRole) |
執行人員 | Procedure.performer.actor |
既有人員 |
procedure.outcome |
0..1 | CodeableConcept |
處置結果 | Procedure.outcome |
原評值文字 |
allergy |
0..* | BackboneElement |
過敏資訊 | HAHAllergyIntolerance |
原 Condition 過敏旗標；擴充物質、確認狀態及反應 |
allergy.substance |
1..1 | CodeableConcept |
物質或過敏狀態 | AllergyIntolerance.code |
新增 |
allergy.verification |
1..1 | CodeableConcept |
確認狀態 | AllergyIntolerance.verificationStatus |
新增 |
allergy.manifestation |
0..* | CodeableConcept |
反應表現 | AllergyIntolerance.reaction.manifestation |
新增 |
consent |
0..* | BackboneElement |
照護同意 | HAHConsent |
新增 |
consent.status |
1..1 | code |
同意狀態 | Consent.status |
新增 |
consent.scope |
1..1 | CodeableConcept |
同意範圍 | Consent.scope |
新增 |
consent.source |
1..1 | Reference(HAHDocumentReference) |
來源文件 | Consent.sourceReference |
新增；也可用 sourceAttachment |
communication |
0..* | BackboneElement |
照會與交班 | HAHCommunication |
queryNote.js、handover_notification.py |
communication.category |
1..* | CodeableConcept |
溝通類型 | Communication.category |
新增分類 |
communication.sender |
1..1 | Reference(Practitioner or PractitionerRole or Organization or RelatedPerson) |
發送者 | Communication.sender |
queryNote.js |
communication.recipient |
1..* | Reference(Resource) |
接收者 | Communication.recipient |
queryNote.js |
communication.sent |
1..1 | dateTime |
發送時間 | Communication.sent |
queryNote.js |
communication.content |
1..* | string |
內容 | Communication.payload.contentString |
queryNote.js、交班內容 |
communication.request |
0..* | Reference(HAHServiceRequest) |
依據請求 | Communication.basedOn |
queryNote.js |
task |
0..* | BackboneElement |
照護工作 | HAHVisitTask |
task.js |
task.code |
1..1 | CodeableConcept |
工作類型 | Task.code |
selectedJobs 分類 |
task.status |
1..1 | code |
工作狀態 | Task.status |
task.js |
task.owner |
1..1 | Reference(Practitioner or PractitionerRole or Organization or CareTeam) |
負責人或團隊 | Task.owner |
task.js |
task.scheduled |
0..1 | Period |
預定執行期限 | Task.restriction.period |
修正原 executionPeriod 語意 |
task.actual |
0..1 | Period |
實際執行期間 | Task.executionPeriod |
新增實際起訖 |
task.location |
0..1 | Reference(Location) |
工作地點 | Task.location |
task.js |
attachment |
0..* | BackboneElement |
照護附件 | HAHDocumentReference |
fhirResources.js |
attachment.type |
1..1 | CodeableConcept |
附件種類 | DocumentReference.type |
既有附件 |
attachment.content |
1..* | Attachment |
附件內容或網址 | DocumentReference.content.attachment |
fhirResources.js |
attachment.author |
1..* | Reference(Resource) |
作者 | DocumentReference.author |
fhirResources.js |
summary |
0..1 | BackboneElement |
結案與轉銜摘要 | HAHCompositionSummary、HAHBundleSummary |
新增文件交換 |
summary.type |
1..1 | CodeableConcept |
摘要種類 | Composition.type |
新增 |
summary.date |
1..1 | dateTime |
文件時間 | Composition.date |
新增 |
summary.followUp |
1..1 | string |
後續照護與待辦 | Composition.section[followUp].text |
原交班與轉送資料 |
summary.documentId |
1..1 | Identifier |
文件識別碼 | Bundle.identifier |
新增 |