description: 西醫診所門診病摘(MedicalClinicRecord)之資料模型 package_name: tw.cohesion.fhir.clinemr derivation: specialization name: MedicalClinicRecordModel type: https://fhir.cohesiondata.com/clinemr/StructureDefinition/MedicalClinicRecordModel elements: documentInfo: type: BackboneElement short: 病歷文件資料 index: 0 elements: hisdocPK: {type: Identifier, short: HIS病歷唯一碼, index: 1} hospitalId: {type: Identifier, short: 醫事機構代碼, index: 2} hospitalName: {type: string, short: 醫事機構名稱, index: 3} sheetInfo: type: BackboneElement short: 病歷表單資料 index: 4 elements: sheetId: {type: Identifier, short: 病歷表單編號, index: 5} sheetName: {type: string, short: 病歷表單名稱, index: 6} sheetVersion: {type: id, short: 病歷表單版本, index: 7} required: [sheetVersion, sheetName, sheetId] docInfo: type: BackboneElement short: 病歷文件資料 index: 8 elements: docConfidentialityCode: {type: code, short: 文件敏感性, index: 9} createTime: {type: dateTime, short: 文件產生時間, index: 10} required: [createTime, docConfidentialityCode] required: [hospitalId, docInfo, hisdocPK, hospitalName, sheetInfo] patientInfo: type: BackboneElement short: 病人基本資料 index: 11 elements: chatNo: {type: Identifier, short: 病歷號, index: 12} contactInfo: type: BackboneElement short: 聯絡資訊 index: 18 elements: homeTel: {type: ContactPoint, short: 住宅電話, index: 19} officeTel: {type: ContactPoint, short: 公司電話, index: 20} mobile: {type: ContactPoint, short: 行動電話, index: 21} visitIdentity: {type: CodeableConcept, short: 就醫身份, index: 15} email: {type: ContactPoint, short: 病人電子郵件地址, index: 32} addressInfo: type: BackboneElement short: 病人相關住址 index: 25 elements: originalAddressInfo: type: BackboneElement short: 病人戶籍地址資料 index: 26 elements: originalAddressZipCode: {type: code, short: 病人戶籍地址郵遞區號, index: 27} originalAddresLocation: {type: Address, short: 病人戶籍地址, index: 28} contactAddressInfo: type: BackboneElement short: 病人聯絡地址資料 index: 29 elements: contactAddressZipCode: {type: code, short: 病人聯絡地址郵遞區號, index: 30} contactAddressLocation: {type: Address, short: 病人聯絡地址, index: 31} childNumber: {type: integer, short: 病人子女數, index: 42} occupation: {type: CodeableConcept, short: 職業, index: 24} personalIDNumber: {type: Identifier, short: 身分證號, index: 17} birthDate: {type: date, short: 出生日期, index: 14} history: {type: CodeableConcept, short: 過去病史, index: 33} marriageStatus: {type: CodeableConcept, short: 婚姻, index: 23} patientName: {type: HumanName, short: 病人姓名, index: 13} emergencyContactInfo: type: BackboneElement short: 緊急聯絡人相關資訊 array: true index: 35 elements: emName: {type: HumanName, short: 緊急聯絡人姓名, index: 36} emrelationshp: {type: code, short: 緊急聯絡人與病人關係, index: 37} emergencyContactWay: type: BackboneElement short: 緊急聯絡人聯絡方式 index: 38 elements: emHomeTel: {type: ContactPoint, short: 緊急聯絡人住宅電話, index: 39} emOfficeTel: {type: ContactPoint, short: 緊急聯絡人公司電話, index: 40} emMobile: {type: ContactPoint, short: 緊急聯絡人行動電話, index: 41} education: {type: CodeableConcept, short: 病人教育程度, index: 43} allergy: {type: string, short: 過敏記錄, index: 34} gender: {type: code, short: 性別, index: 16} bloodtype: {type: CodeableConcept, short: 自述血型, index: 22} required: [patientName, visitIdentity, gender, personalIDNumber, chatNo] encounter: type: BackboneElement short: 病人當次看診之相關資訊 index: 44 elements: doctorAdvise: {type: Annotation, short: 醫師囑咐, index: 74} department: {type: CodeableConcept, short: 看診科別, index: 47} majorInjuryInfo: type: BackboneElement short: 重大傷病相關資訊 array: true min: 1 index: 60 elements: majorInjuryFlag: {type: Annotation, short: 重大傷病註記, index: 61} majorInjuryContent: type: BackboneElement short: 重大傷病代碼與病名 array: true index: 62 elements: majorInjuryCode: {type: code, short: 重大傷病代碼, index: 63} majorInjuryName: {type: string, short: 重大傷病名稱, index: 64} required: [majorInjuryName, majorInjuryCode] required: [majorInjuryFlag] diagnosisContent: type: BackboneElement short: 診斷代碼與名稱 array: true min: 1 index: 65 elements: diagcode: {type: code, short: 診斷代碼, index: 66} diagName: {type: string, short: 診斷名稱, index: 67} required: [diagName, diagcode] weightUnit: {type: code, short: 病人體重單位, index: 57} heightUnit: {type: code, short: 病人身高單位, index: 55} bodytemperature: {type: CodeableConcept, short: 病人體溫, index: 58} visitDate: {type: dateTime, short: 掛號(報到)日期時間, index: 45} doctorId: {type: Identifier, short: 看診醫師身分證號, index: 48} weight: {type: CodeableConcept, short: 病人體重, index: 56} pulse: {type: CodeableConcept, short: 病人脈搏, index: 53} visitSeq: {type: Identifier, short: 掛號序號, index: 46} doctorName: {type: HumanName, short: 看診醫師姓名, index: 49} chiefComplain: {type: Annotation, short: 病人主訴, index: 59} treatmenInfo: type: BackboneElement short: 處置相關內容 array: true index: 68 elements: treatmentRegionNHICode: {type: code, short: 處置部位代碼, index: 69} treatmentNHICCode: {type: code, short: 處置健保碼, index: 70} treatmentHospCode: {type: code, short: 處置院內碼, index: 71} treatmentDescription: {type: string, short: 處置說明, index: 72} treatmentDose: {type: decimal, short: 處置劑量, index: 73} patientBloodPressure: type: BackboneElement short: 病人血壓 index: 50 elements: systolicPressure: {type: CodeableConcept, short: 收縮壓, index: 51} diastoicPressure: {type: CodeableConcept, short: 舒張壓, index: 52} height: {type: CodeableConcept, short: 病人身高, index: 54} required: [visitDate, department, doctorId, chiefComplain, majorInjuryInfo, doctorName, diagnosisContent, visitSeq] drugInfo: type: BackboneElement short: 用藥紀錄相關內容 array: true index: 75 elements: drugStartDate: {type: date, short: 用藥開始日期, index: 83} drugName: {type: string, short: 藥品商品名, index: 78} totalAmount: {type: decimal, short: 藥品總劑量, index: 86} frequency: {type: CodeableConcept, short: 藥品的使用頻率, index: 82} dose: {type: decimal, short: 用量, index: 79} days: {type: decimal, short: 服藥天數, index: 85} route: {type: CodeableConcept, short: 藥品服用方法, index: 81} drugNHICCode: {type: code, short: 藥品健保碼, index: 76} drugCode: {type: code, short: 藥品藥品碼, index: 77} drugUseRegion: {type: CodeableConcept, short: 藥品使用部位, index: 88} drugEndDate: {type: date, short: 用藥結束日期, index: 84} doseUnit: {type: string, short: 用量單位, index: 80} prescriptionMethod: {type: CodeableConcept, short: 藥品調劑方式, index: 87} required: [totalAmount, drugName, route, doseUnit, drugEndDate, drugCode, days, dose, drugStartDate, frequency] examiationInfo: type: BackboneElement short: 檢驗檢查相關內容 array: true index: 89 elements: examOrderDate: type: dateTime short: 檢驗檢查開單日期 index: 90 elements: orderHospitalID: {type: code, short: 檢驗檢查開單醫事機構代碼, index: 91} orderHospitalName: {type: string, short: 檢驗檢查開單醫事機構名稱, index: 92} examHospitalID: {type: code, short: 檢驗檢查執行醫事機構代碼, index: 93} examHospitalName: type: string short: 檢驗檢查執行醫事機構名稱 index: 94 elements: examDate: {type: dateTime, short: 檢查日期, index: 95} verifyDate: {type: dateTime, short: 報告日期, index: 96} testNHICode: {type: code, short: 健保檢驗檢查代碼, index: 97} testName: {type: string, short: 檢驗檢查名稱, index: 98} testResult: {type: string, short: 檢驗檢查結果值, index: 99} resultUnit: {type: string, short: 檢驗檢查結果單位, index: 100} resultFlag: {type: CodeableConcept, short: 檢驗檢查結果判斷註記, index: 101} resultComment: {type: Annotation, short: 檢驗檢查結果備註說明, index: 102} required: [examDate, testName] required: [examHospitalName, examHospitalID, orderHospitalName, orderHospitalID] imageInfo: type: BackboneElement short: 圖檔報告內容 array: true index: 103 elements: imageFileName: {type: Attachment, short: 圖檔報告名稱, index: 104} imageContent: {type: Attachment, short: 圖檔報告內容, index: 105} required: [imageFileName, imageContent] referenceInfo: type: BackboneElement short: 參考附件資料內容 array: true index: 106 elements: referenceDocFileName: {type: Attachment, short: 附件檔名, index: 107} referenceDocContent: {type: Attachment, short: 附件內容, index: 108} required: [referenceDocFileName, referenceDocContent] package_version: 1.0.0 class: logical kind: logical url: https://fhir.cohesiondata.com/clinemr/StructureDefinition/MedicalClinicRecordModel base: http://hl7.org/fhir/StructureDefinition/Base version: 1.0.0 required: [encounter, patientInfo, documentInfo]