description: 用於描述門診病歷邏輯模型
package_name: tw.gov.mohw.emr
derivation: specialization
name: PMRModel
type: https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRModel
elements:
  hospital:
    type: BackboneElement
    short: 醫事機構
    index: 0
    elements:
      hospitalId: {type: Identifier, short: 醫事機構代碼, index: 1}
      hospitalName: {type: string, short: 醫事機構名稱, index: 2}
    required: [hospitalId, hospitalName]
  department: {type: CodeableConcept, short: 科別, index: 17}
  prescriptionContent:
    type: BackboneElement
    short: 處方內容
    array: true
    min: 1
    index: 36
    elements:
      doseUnits: {type: string, short: 劑量單位, index: 44}
      genericName: {type: string, short: 學名, index: 41}
      medicationDays: {type: decimal, short: 給藥日數, index: 47}
      actualUnits: {type: string, short: 實際給藥總量單位, index: 51}
      totalAmount: {type: decimal, short: 給藥總量, index: 48}
      totalUnits: {type: string, short: 給藥總量單位, index: 49}
      item: {type: Identifier, short: 項次, index: 37}
      frequency: {type: CodeableConcept, short: 頻率, index: 45}
      dose: {type: decimal, short: 劑量, index: 43}
      routeofAdministration: {type: CodeableConcept, short: 給藥途徑, index: 46}
      note: {type: Annotation, short: 註記, index: 53}
      drugCode: {type: code, short: 藥品代碼, index: 39}
      selfPaynote: {type: Annotation, short: 自費註記, index: 54}
      actualAmount: {type: decimal, short: 實際給藥總量, index: 50}
      brandName: {type: string, short: 藥品商品名稱, index: 40}
      dosageForm: {type: string, short: 劑型, index: 42}
      typesofPrescription: {type: CodeableConcept, short: 處方箋種類註記, index: 38}
      powdered: {type: code, short: 磨粉註記, index: 52}
    required: [totalAmount, powdered, genericName, typesofPrescription, brandName, item, drugCode, medicationDays, totalUnits, dose, routeofAdministration, doseUnits, dosageForm, frequency]
  diagnosis:
    type: BackboneElement
    short: 診斷
    array: true
    min: 1
    index: 18
    elements:
      icdCode: {type: code, short: 國際疾病分類代碼, index: 19}
      icdName: {type: string, short: 國際疾病分類名稱, index: 20}
      note: {type: Annotation, short: 註記, index: 21}
    required: [icdName, icdCode]
  physicianName: {type: HumanName, short: 醫師姓名, index: 57}
  patientInformation:
    type: BackboneElement
    short: 病人基本資料
    index: 3
    elements:
      majorIllness: {type: CodeableConcept, short: 重大傷病, array: true, min: 1, index: 11}
      age: {type: Age, short: 就診年齡, index: 13}
      occupation: {type: CodeableConcept, short: 職業, index: 14}
      name: {type: HumanName, short: 病人性名, index: 6}
      personalIDNumber: {type: Identifier, short: 身分證號, index: 4}
      birthDate: {type: date, short: 出生日期, index: 8}
      bloodType: {type: CodeableConcept, short: 血型, index: 9}
      rhType: {type: CodeableConcept, short: D抗原性, index: 10}
      historyOfAllergies: {type: CodeableConcept, short: 過敏史, array: true, min: 1, index: 12}
      gender: {type: code, short: 性別, index: 7}
      chartNo: {type: Identifier, short: 病歷號碼, index: 5}
      identityType: {type: CodeableConcept, short: 就醫身分別, index: 15}
    required: [identityType, age, majorIllness, gender, name, personalIDNumber, birthDate, chartNo, bloodType, historyOfAllergies, rhType]
  opdDate: {type: dateTime, short: 門診日期, index: 16}
  opdImage: {type: BackboneElement, short: 門診圖像, array: true, index: 56}
  procedure:
    type: BackboneElement
    short: 處置項目
    array: true
    min: 1
    index: 26
    elements:
      amount: {type: CodeableConcept, short: 數量, index: 31}
      procedureName: {type: string, short: 處置名稱, index: 29}
      item: {type: Identifier, short: 項次, index: 27}
      part: {type: CodeableConcept, short: 部位, array: true, index: 33}
      frequency: {type: CodeableConcept, short: 頻率, index: 30}
      note: {type: Annotation, short: 註記, index: 34}
      selfPaynote: {type: Annotation, short: 自費註記, index: 35}
      units: {type: CodeableConcept, short: 單位, index: 32}
      procedureCode: {type: code, short: 處置代碼, index: 28}
    required: [procedureName, procedureCode, item, units, amount]
  conditionSummary:
    type: BackboneElement
    short: 病情摘要
    index: 22
    elements:
      subjective: {type: Annotation, short: 主觀描述, index: 23}
      objective: {type: Annotation, short: 客觀描述, index: 24}
      assessment: {type: Annotation, short: 評估, index: 25}
    required: [objective, assessment, subjective]
  familyTree: {type: BackboneElement, short: 家族圖譜, array: true, index: 55}
package_version: 0.2.0
class: logical
kind: logical
url: https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRModel
base: http://hl7.org/fhir/StructureDefinition/Element
version: 0.2.0
required: [prescriptionContent, department, opdDate, patientInformation, diagnosis, procedure, hospital, physicianName, conditionSummary]