醫療影像及報告實作指引
0.1.0 - DSTU0 ci-build
醫療影像及報告實作指引 - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
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<div xmlns="http://www.w3.org/1999/xhtml"><a name="Composition_ImageComposition"> </a><p class="res-header-id"><b>Generated Narrative: Composition ImageComposition</b></p><a name="ImageComposition"> </a><a name="hcImageComposition"> </a><a name="hcImageComposition-en-US"> </a><p><b>identifier</b>: <code>https://dep.mohw.gov.tw/</code>/202212231005</p><p><b>status</b>: Final</p><p><b>type</b>: <span title="Codes:{http://loinc.org 18782-3}">Radiology Study observation (narrative)</span></p><p><b>encounter</b>: <a href="Encounter-TWCoreEncounter.html">Encounter: status = finished; class = pre-admission (ActCode#PRENC); period = 2022-08-01 17:00:14-0500 --> 2022-08-01 18:00:14-0500; reasonCode = Primary malignant neoplasm of lung (disorder)</a></p><p><b>date</b>: 2022-12-23 14:30:00+0800</p><p><b>author</b>: <a href="Organization-TWCoreOrganization.html">Organization 台北榮民總醫院</a></p><p><b>title</b>: 醫療影像及報告</p><h3>Attesters</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Mode</b></td><td><b>Party</b></td></tr><tr><td style="display: none">*</td><td>Official</td><td><a href="Organization-TWCoreOrganization.html">Organization 台北榮民總醫院</a></td></tr></table></div>
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<title value="醫療影像及報告"/>
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<title value="Relevant diagnostic tests/laboratory data Narrative"/>
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<div xmlns="http://www.w3.org/1999/xhtml"><a name="Patient_TWCorePatient"> </a><p class="res-header-id"><b>Generated Narrative: Patient TWCorePatient</b></p><a name="TWCorePatient"> </a><a name="hcTWCorePatient"> </a><a name="hcTWCorePatient-en-US"> </a><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;">胖吉 綠 (official) Male, DoB: 1987-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))</p><hr/><table class="grid"><tr><td style="background-color: #f3f5da" title="Ways to contact the Patient">Contact Detail</td><td colspan="3"><ul><li>ph: 0912345678</li><li>台北市北投區明德路365號(home)</li></ul></td></tr><tr><td style="background-color: #f3f5da" title="Nominated Contact: Emergency Contact">Emergency Contact:</td><td colspan="3"><ul><li>大吉 綠 (Official) (Male)</li><li>台北市北投區明德路365號(home)</li><li>ph: 0987654321</li></ul></td></tr></table></div>
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<div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_TWCoreOrganization"> </a><p class="res-header-id"><b>Generated Narrative: Organization TWCoreOrganization</b></p><a name="TWCoreOrganization"> </a><a name="hcTWCoreOrganization"> </a><a name="hcTWCoreOrganization-en-US"> </a><p><b>identifier</b>: <code>https://www.nhi.gov.tw</code>/0601160016</p><p><b>active</b>: true</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/organization-type prov}">Healthcare Provider</span></p><p><b>name</b>: 台北榮民總醫院</p><p><b>telecom</b>: ph: 02-28712121</p><p><b>address</b>: 石牌路二段201號 台北市 11219 台灣 </p></div>
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<div xmlns="http://www.w3.org/1999/xhtml"><a name="Practitioner_TWCorePractitioner"> </a><p class="res-header-id"><b>Generated Narrative: Practitioner TWCorePractitioner</b></p><a name="TWCorePractitioner"> </a><a name="hcTWCorePractitioner"> </a><a name="hcTWCorePractitioner-en-US"> </a><p><b>identifier</b>: Medical License number/tvgh001 (use: official, )</p><p><b>active</b>: true</p><p><b>name</b>: 大吉 連 (Official)</p><p><b>gender</b>: Male</p></div>
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<name>
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<family value="連"/>
<given value="大吉"/>
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<gender value="male"/>
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<div xmlns="http://www.w3.org/1999/xhtml"><a name="Encounter_TWCoreEncounter"> </a><p class="res-header-id"><b>Generated Narrative: Encounter TWCoreEncounter</b></p><a name="TWCoreEncounter"> </a><a name="hcTWCoreEncounter"> </a><a name="hcTWCoreEncounter-en-US"> </a><p><b>status</b>: Finished</p><p><b>class</b>: <a href="http://terminology.hl7.org/5.5.0/CodeSystem-v3-ActCode.html#v3-ActCode-PRENC">ActCode</a> PRENC: pre-admission</p><p><b>subject</b>: <a href="Patient-TWCorePatient.html">胖吉 綠 (official) Male, DoB: 1987-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))</a></p><h3>Participants</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td><td><b>Period</b></td><td><b>Individual</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ParticipationType PPRF}">primary performer</span></td><td>2022-08-01 17:00:14-0500 --> 2022-08-01 18:00:14-0500</td><td><a href="Practitioner-TWCorePractitioner.html">Practitioner 大吉 連 (official)</a></td></tr></table><p><b>period</b>: 2022-08-01 17:00:14-0500 --> 2022-08-01 18:00:14-0500</p><p><b>reasonCode</b>: <span title="Codes:{http://snomed.info/sct 93880001}">Primary malignant neoplasm of lung (disorder)</span></p></div>
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<div xmlns="http://www.w3.org/1999/xhtml"><a name="Condition_TWCoreCondition"> </a><p class="res-header-id"><b>Generated Narrative: Condition TWCoreCondition</b></p><a name="TWCoreCondition"> </a><a name="hcTWCoreCondition"> </a><a name="hcTWCoreCondition-en-US"> </a><p><b>clinicalStatus</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/condition-clinical active}">Active</span></p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/condition-category encounter-diagnosis}">Encounter Diagnosis</span></p><p><b>code</b>: <span title="Codes:{https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2021-tw A15.0}">肺結核</span></p><p><b>subject</b>: <a href="Patient-TWCorePatient.html">胖吉 綠 (official) Male, DoB: 1987-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))</a></p><p><b>asserter</b>: <a href="Practitioner-TWCorePractitioner.html">Practitioner 大吉 連 (official)</a></p></div>
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<code value="A15.0"/>
<display value="肺結核"/>
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<subject>🔗
<reference value="Patient/TWCorePatient"/>
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<asserter>🔗
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<div xmlns="http://www.w3.org/1999/xhtml"><a name="ImagingStudy_ImagingStudyBase"> </a><p class="res-header-id"><b>Generated Narrative: ImagingStudy ImagingStudyBase</b></p><a name="ImagingStudyBase"> </a><a name="hcImagingStudyBase"> </a><a name="hcImagingStudyBase-en-US"> </a><p><b>identifier</b>: Study instancce UID/urn:oid:2.25.284733062255854756631429402605810248731 (use: official, ), Accession ID/2ffe0c20-50d8-49df-85f6-6452d1d201b9 (use: official, )</p><p><b>status</b>: Available</p><p><b>subject</b>: <a href="Patient-TWCorePatient.html">胖吉 綠 (official) Male, DoB: 1987-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))</a></p><p><b>started</b>: 2024-01-01 11:01:20+0300</p><p><b>endpoint</b>: <a href="Endpoint-MitwEndpoint.html">Endpoint: status = active; connectionType = DICOM WADO-RS (Endpoint Connection Type#dicom-wado-rs); payloadType = ; payloadMimeType = application/dicom; address = http://localhost:8081/dicom-web</a></p><p><b>numberOfSeries</b>: 1</p><p><b>numberOfInstances</b>: 1</p><p><b>procedureCode</b>: <span title="Codes:{https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-pcs-2021-tw BW40ZZZ}">腹部超音波</span></p><blockquote><p><b>series</b></p><p><b>uid</b>: 2.25.88017001449189502323411118737039844242</p><p><b>modality</b>: <a href="http://dicom.nema.org/resources/ontology/DCM#DCM-US">DICOM Controlled Terminology Definitions</a> US: Ultrasound</p><p><b>numberOfInstances</b>: 1</p><p><b>bodySite</b>: <a href="http://snomed.info/id/251007">SNOMED CT (all versions)</a> 251007: Pectoral region</p><h3>Instances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Uid</b></td><td><b>SopClass</b></td></tr><tr><td style="display: none">*</td><td>2.25.284548087604447302186649612333159050027</td><td>unknown urn:oid:1.2.840.10008.5.1.4.1.1.3.1: urn:oid:1.2.840.10008.5.1.4.1.1.3.1</td></tr></table></blockquote></div>
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<display value="Study instancce UID"/>
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<system value="urn:dicom:uid"/>
<value
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<identifier>
<use value="official"/>
<type>
<coding>
<system
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<code value="ACSN"/>
<display value="Accession ID"/>
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<system value="http://www.moi.gov.tw/"/>
<value value="2ffe0c20-50d8-49df-85f6-6452d1d201b9"/>
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<status value="available"/>
<subject>🔗
<reference value="Patient/TWCorePatient"/>
</subject>
<started value="2024-01-01T11:01:20+03:00"/>
<endpoint>🔗
<reference value="Endpoint/MitwEndpoint"/>
</endpoint>
<numberOfSeries value="1"/>
<numberOfInstances value="1"/>
<procedureCode>
<coding>
<system
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<code value="BW40ZZZ"/>
<display value="腹部超音波"/>
</coding>
</procedureCode>
<series>
<uid value="2.25.88017001449189502323411118737039844242"/>
<modality>
<system value="http://dicom.nema.org/resources/ontology/DCM"/>
<code value="US"/>
</modality>
<numberOfInstances value="1"/>
<bodySite>
<system value="http://snomed.info/sct"/>
<code value="251007"/>
<display value="Pectoral region"/>
</bodySite>
<instance>
<uid value="2.25.284548087604447302186649612333159050027"/>
<sopClass>
<system value="urn:ietf:rfc:3986"/>
<code value="urn:oid:1.2.840.10008.5.1.4.1.1.3.1"/>
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</instance>
</series>
</ImagingStudy>
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</entry>
<entry>
<fullUrl value="https://hapi.fhir.tw/fhir/Media/MediaBase"/>
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<Media>
<id value="MediaBase"/>
<meta>
<profile
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<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Media_MediaBase"> </a><p class="res-header-id"><b>Generated Narrative: Media MediaBase</b></p><a name="MediaBase"> </a><a name="hcMediaBase"> </a><a name="hcMediaBase-en-US"> </a><p><b>status</b>: Completed</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/media-type image}">Image</span></p><p><b>view</b>: <span title="Codes:{http://snomed.info/sct 272483007}">True projection</span></p><p><b>subject</b>: <a href="Patient-TWCorePatient.html">胖吉 綠 (official) Male, DoB: 1987-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))</a></p><p><b>created</b>: 2022-12-22 15:30:00+0000</p><p><b>issued</b>: 2022-12-22 16:00:00+0000</p><p><b>operator</b>: <a href="Practitioner-TWCorePractitioner.html">Practitioner 大吉 連 (official)</a></p><p><b>reasonCode</b>: <span title="Codes:{http://snomed.info/sct 357009}">Closed fracture trapezoid</span></p><p><b>bodySite</b>: <span title="Codes:{http://snomed.info/sct 1927002}">Entire left elbow region</span></p><p><b>deviceName</b>: ntegris BH3000</p><p><b>height</b>: 512</p><p><b>width</b>: 512</p><h3>Contents</h3><table class="grid"><tr><td style="display: none">-</td><td><b>ContentType</b></td><td><b>Url</b></td></tr><tr><td style="display: none">*</td><td>image/png</td><td><a href="http://example.nondicom.url">http://example.nondicom.url</a></td></tr></table></div>
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<status value="completed"/>
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<code value="image"/>
<display value="Image"/>
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<view>
<coding>
<system value="http://snomed.info/sct"/>
<code value="272483007"/>
<display value="True projection"/>
</coding>
</view>
<subject>🔗
<reference value="Patient/TWCorePatient"/>
</subject>
<createdDateTime value="2022-12-22T15:30:00Z"/>
<issued value="2022-12-22T16:00:00Z"/>
<operator>🔗
<reference value="Practitioner/TWCorePractitioner"/>
</operator>
<reasonCode>
<coding>
<system value="http://snomed.info/sct"/>
<code value="357009"/>
<display value="Closed fracture trapezoid"/>
</coding>
</reasonCode>
<bodySite>
<coding>
<system value="http://snomed.info/sct"/>
<code value="1927002"/>
<display value="Entire left elbow region"/>
</coding>
</bodySite>
<deviceName value="ntegris BH3000"/>
<height value="512"/>
<width value="512"/>
<content>
<contentType value="image/png"/>
<url value="http://example.nondicom.url"/>
</content>
</Media>
</resource>
</entry>
<entry>
<fullUrl value="https://hapi.fhir.tw/fhir/Endpoint/MitwEndpoint"/>
<resource>
<Endpoint>
<id value="MitwEndpoint"/>
<meta>
<profile
value="https://hapi.fhir.tw/fhir/StructureDefinition/MitwEndpoint"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Endpoint_MitwEndpoint"> </a><p class="res-header-id"><b>Generated Narrative: Endpoint MitwEndpoint</b></p><a name="MitwEndpoint"> </a><a name="hcMitwEndpoint"> </a><a name="hcMitwEndpoint-en-US"> </a><p><b>status</b>: Active</p><p><b>connectionType</b>: <a href="http://terminology.hl7.org/5.5.0/CodeSystem-endpoint-connection-type.html#endpoint-connection-type-dicom-wado-rs">Endpoint Connection Type</a> dicom-wado-rs: DICOM WADO-RS</p><p><b>payloadType</b>: <span title="Codes:">DICOM</span></p><p><b>payloadMimeType</b>: application/dicom</p><p><b>address</b>: <a href="http://localhost:8081/dicom-web">http://localhost:8081/dicom-web</a></p></div>
</text>
<status value="active"/>
<connectionType>
<system
value="http://terminology.hl7.org/CodeSystem/endpoint-connection-type"/>
<code value="dicom-wado-rs"/>
</connectionType>
<payloadType>
<text value="DICOM"/>
</payloadType>
<payloadMimeType value="application/dicom"/>
<address value="http://localhost:8081/dicom-web"/>
</Endpoint>
</resource>
</entry>
<entry>
<fullUrl
value="https://hapi.fhir.tw/fhir/Observation/ObservationImagingResult"/>
<resource>
<Observation>
<id value="ObservationImagingResult"/>
<meta>
<profile
value="https://hapi.fhir.tw/fhir/StructureDefinition/Observation-Imaging-Result"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Observation_ObservationImagingResult"> </a><p class="res-header-id"><b>Generated Narrative: Observation ObservationImagingResult</b></p><a name="ObservationImagingResult"> </a><a name="hcObservationImagingResult"> </a><a name="hcObservationImagingResult-en-US"> </a><p><b>identifier</b>: Accession ID/2ffe0c20-50d8-49df-85f6-6452d1d201b9 (use: official, )</p><p><b>status</b>: Final</p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/observation-category imaging}">Imaging</span></p><p><b>code</b>: <span title="Codes:{https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-b B00B0ZZ}">脊髓一般放射線攝影，使用高滲透壓顯影劑</span></p><p><b>subject</b>: <a href="Patient-TWCorePatient.html">胖吉 綠 (official) Male, DoB: 1987-01-01 ( National Person Identifier where the xxx is the ISO table 3166 3-character (alphabetic) country code (use: official, ))</a></p><p><b>effective</b>: 2023-08-01 17:00:14-0500</p><p><b>performer</b>: <a href="Practitioner-TWCorePractitioner.html">Practitioner 大吉 連 (official)</a></p><p><b>value</b>: LUNGS AND PLEURA: Clear lungs. Normal pulmonary vascularity. No pleural effusion. No pneumothorax.</p></div>
</text>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="https://hapi.fhir.tw/fhir/CodeSystem/ImageIdentifierType"/>
<code value="ACSN"/>
<display value="Accession ID"/>
</coding>
</type>
<system value="http://www.moi.gov.tw/"/>
<value value="2ffe0c20-50d8-49df-85f6-6452d1d201b9"/>
</identifier>
<status value="final"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/observation-category"/>
<code value="imaging"/>
<display value="Imaging"/>
</coding>
</category>
<code>
<coding>
<system
value="https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-b"/>
<code value="B00B0ZZ"/>
<display value="脊髓一般放射線攝影，使用高滲透壓顯影劑"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/TWCorePatient"/>
</subject>
<effectiveDateTime value="2023-08-01T17:00:14-05:00"/>
<performer>🔗
<reference value="Practitioner/TWCorePractitioner"/>
</performer>
<valueString
value="LUNGS AND PLEURA: Clear lungs. Normal pulmonary vascularity. No pleural effusion. No pneumothorax."/>
</Observation>
</resource>
</entry>
<entry>
<fullUrl
value="https://hapi.fhir.tw/fhir/DiagnosticReport/ImageDiagnosticReport"/>
<resource>
<DiagnosticReport>
<id value="ImageDiagnosticReport"/>
<meta>
<profile
value="https://hapi.fhir.tw/fhir/StructureDefinition/DiagnosticReport-Image"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><h2><span title="Codes: {https://fhir.tw/fhir/ig/lungcancer/CodeSystem/ICD-10-procedurecode BW24ZZZ}">Computerized Tomography (CT Scan) of Chest and Abdomen</span> (<span title="Codes: {http://loinc.org LP29684-5}">Radiology</span>)</h2><table class="grid"><tr><td>Subject</td><td><b>胖吉 綠 (OFFICIAL)</b> male, DoB: 1987-01-01 ( Social Beneficiary Identifier: A123456789)</td></tr><tr><td>Reported</td><td>2022-08-30 10:35:32+0800</td></tr><tr><td>Identifier:</td><td>Medical record number: 01260526</td></tr></table><p><b>ImagingStudy Finding :</b></p><table class="grid"><tr><td><b>Code</b></td><td><b>Value</b></td><td><b>When For</b></td></tr><tr><td><a href="Observation-ObservationImagingResult.html"><span title="Codes: {https://fhir.tw/fhir/ig/lungcancer/CodeSystem/ICD-10-procedurecode BW24ZZZ}">Computerized Tomography (CT Scan) of Chest and Abdomen</span></a></td><td>LUNGS AND PLEURA: Clear lungs. Normal pulmonary vascularity. No pleural effusion. No pneumothorax.</td><td>2022-08-30</td></tr></table><p><b>ImagingStudy Impression :</b></p><p>No acute abnormality</p><p><b>Coded Conclusions :</b></p><ul><li><span title="Codes: {http://snomed.info/sct 3368006}">Dull chest pain</span></li></ul></div>
</text>
<identifier>
<system value="https://www.vghtpe.gov.tw/"/>
<value value="123456"/>
</identifier>
<status value="final"/>
<category>
<coding>
<system value="http://loinc.org"/>
<code value="LP29684-5"/>
<display value="Radiology"/>
</coding>
</category>
<code>
<coding>
<system
value="https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-b"/>
<code value="B00B0ZZ"/>
<display value="脊髓一般放射線攝影，使用高滲透壓顯影劑"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/TWCorePatient"/>
</subject>
<encounter>🔗
<reference value="Encounter/TWCoreEncounter"/>
</encounter>
<effectiveDateTime value="2023-08-01T17:00:14-05:00"/>
<issued value="2022-08-30T14:35:32.631Z"/>
<performer>🔗
<reference value="Practitioner/TWCorePractitioner"/>
</performer>
<resultsInterpreter>🔗
<reference value="Practitioner/TWCorePractitioner"/>
</resultsInterpreter>
<result>🔗
<reference value="Observation/ObservationImagingResult"/>
</result>
<imagingStudy>🔗
<reference value="ImagingStudy/ImagingStudyBase"/>
</imagingStudy>
<conclusion value="No acute abnormality"/>
<conclusionCode>
<coding>
<system value="http://snomed.info/sct"/>
<code value="3368006"/>
<display value="Dull chest pain"/>
</coding>
</conclusionCode>
</DiagnosticReport>
</resource>
</entry>
</Bundle>