1. 遭遇資源 — 就診/住院
相遇 描述了患者和醫療保健提供者之間的互動——從門診到住院、到急診室、到遠距醫療。
遭遇結構
| 元素 | 基數 | 類型 | 描述 |
|---|---|---|---|
| 狀態。狀態 | 1..1 | 程式碼 | 計劃 |進行中 |等待 |出院 |已完成 |取消 |輸入錯誤 |
| 類。類別 | 1..* | 可編碼概念 | AMB（門診）| IMP（住院）| EMER（緊急）| VR（遠距醫療） |
| 類型 | 0..* | 可編碼概念 | 具體考試類型 |
| 優先。優先權 | 0..1 | 可編碼概念 | 優先權 |
| 主題。主題 | 1..1 | 參考（患者） | 病人 |
| 參與者。參與者 | 0..* | 骨幹元素 | 醫生和護士參加 |
| 期間。期間 | 0..1 | 時期 | 開始時間-結束時間 |
| 原因。原因 | 0..* | 骨幹元素 | 檢查原因 |
| 診斷。診斷 | 0..* | 骨幹元素 | 診斷與就診有關 |
| 入場。入場 | 0..1 | 骨幹元素 | 入院詳情（preAdmission、入院來源、出院處置） |
| 位置。位置 | 0..* | 骨幹元素 | 房間/病房/床位 |
| 服務提供者 | 0..1 | 參考資料（組織） | 醫療設施 |
例如：門診就診
{
"resourceType": "Encounter",
"id": "encounter-outpatient-001",
"status": "completed",
"class": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"code": "AMB",
"display": "ambulatory"
}
]
}
],
"type": [
{
"coding": [
{
"system": "http://snomed.info/sct",
"code": "185349003",
"display": "Encounter for check up"
}
],
"text": "Khám sức khỏe tổng quát"
}
],
"subject": {
"reference": "Patient/patient-001",
"display": "Nguyễn Văn A"
},
"participant": [
{
"type": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
"code": "ATND",
"display": "attender"
}
]
}
],
"actor": {
"reference": "Practitioner/practitioner-001",
"display": "BS. Trần Thị B"
}
}
],
"period": {
"start": "2025-01-15T08:00:00+07:00",
"end": "2025-01-15T08:45:00+07:00"
},
"reason": [
{
"use": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/encounter-reason-use",
"code": "CC",
"display": "Chief Complaint"
}
]
},
"value": [
{
"concept": {
"text": "Đau đầu và mệt mỏi kéo dài 2 tuần"
}
}
]
}
],
"serviceProvider": {
"reference": "Organization/org-bvdk-001",
"display": "Bệnh viện Đa khoa Trung ương"
}
}
例如：遇到住院
{
"resourceType": "Encounter",
"id": "encounter-inpatient-001",
"status": "in-progress",
"class": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"code": "IMP",
"display": "inpatient encounter"
}
]
}
],
"subject": {
"reference": "Patient/patient-002"
},
"period": {
"start": "2025-01-10T14:30:00+07:00"
},
"admission": {
"admitSource": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/admit-source",
"code": "emd",
"display": "From accident/emergency department"
}
]
},
"preAdmissionIdentifier": {
"system": "http://bvdk.vn/pre-admit",
"value": "PA-20250110-001"
}
},
"location": [
{
"location": {
"reference": "Location/loc-cardiology-bed-12",
"display": "Khoa Tim mạch - Giường 12"
},
"status": "active",
"period": {
"start": "2025-01-10T15:00:00+07:00"
}
}
],
"diagnosis": [
{
"condition": [
{
"reference": {
"reference": "Condition/cond-001"
}
}
],
"use": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/diagnosis-role",
"code": "AD",
"display": "Admission diagnosis"
}
]
}
]
}
]
}
2. 條件資源－診斷/健康問題
條件 記錄患者的診斷、健康問題或醫療狀況。
條件結構
| 元素 | 基數 | 類型 | 描述 |
|---|---|---|---|
| 臨床狀態 | 0..1 | 可編碼概念 | 活躍 |復發|復發|不活躍 |緩解|解決了。已解決 |
| 驗證狀態 | 0..1 | 可編碼概念 | 未經證實 |暫時|差速器 |確認 |反駁 |輸入錯誤 |
| 類別。類別 | 0..* | 可編碼概念 | 問題列表項目 |遭遇診斷 |
| 嚴重程度 | 0..1 | 可編碼概念 | 嚴重程度 (SNOMED CT) |
| 程式碼 | 1..1 | 可編碼概念 | 診斷代碼（ICD-10、SNOMED CT） |
| 身體部位 | 0..* | 可編碼概念 | 身體姿勢 |
| 主題。主題 | 1..1 | 參考（患者） | 病人 |
| 相遇。遭遇 | 0..1 | 參考（遭遇） | 相關訪問 |
| 開始[x] | 0..1 | 日期時間 |年齡 |期間 |範圍 |字串.字串 | 發病時間 |
| 減少[x] | 0..1 | 日期時間 |年齡 |期間 |範圍 |字串.字串 | 緩解時間 |
| 階段。舞台 | 0..* | 骨幹元素 | 疾病階段 |
例如：高血壓的診斷
{
"resourceType": "Condition",
"id": "cond-hypertension-001",
"clinicalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
"code": "active"
}
]
},
"verificationStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
"code": "confirmed"
}
]
},
"category": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/condition-category",
"code": "encounter-diagnosis",
"display": "Encounter Diagnosis"
}
]
}
],
"severity": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "24484000",
"display": "Severe"
}
]
},
"code": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-10",
"code": "I10",
"display": "Essential (primary) hypertension"
},
{
"system": "http://snomed.info/sct",
"code": "38341003",
"display": "Hypertensive disorder"
}
],
"text": "Tăng huyết áp nguyên phát"
},
"subject": {
"reference": "Patient/patient-001",
"display": "Nguyễn Văn A"
},
"encounter": {
"reference": "Encounter/encounter-outpatient-001"
},
"onsetDateTime": "2024-06-15",
"recordedDate": "2025-01-15"
}
病情分期（癌症）
{
"resourceType": "Condition",
"id": "cond-cancer-001",
"code": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-10",
"code": "C34.1",
"display": "Malignant neoplasm of upper lobe, bronchus or lung"
}
],
"text": "Ung thư phổi thùy trên"
},
"subject": {
"reference": "Patient/patient-003"
},
"stage": [
{
"summary": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "258219007",
"display": "Stage 2"
}
]
},
"type": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "260998006",
"display": "Clinical staging (qualifier value)"
}
]
}
}
]
}
3. 觀察資源－觀察結果
觀察 是 FHIR 中最通用的資源 — 用於生命徵象、實驗室結果、社會史、調查、影像測量和臨床評估。
觀察類別
| 類別 | 描述 | 例如 |
|---|---|---|
| 生命徵象 | 活力的跡象 | 血壓、心率、SpO2、體溫 |
| 實驗室 | 測試結果 | HbA1c、葡萄糖、CBC、血脂組 |
| 成像。影像 | 影像結果 | 腫瘤大小 |
| 社會歷史 | 社會史 | 吸煙、飲酒 |
| 調查。調查 | 調查表 | PHQ-9（憂鬱）、VAS（疼痛） |
| 考試。考試 | 臨床檢查 | 體重、身高 |
例如：生命徵象 — 血壓
{
"resourceType": "Observation",
"id": "obs-bp-001",
"status": "final",
"category": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
"code": "vital-signs",
"display": "Vital Signs"
}
]
}
],
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "85354-9",
"display": "Blood pressure panel with all children optional"
}
],
"text": "Huyết áp"
},
"subject": {
"reference": "Patient/patient-001"
},
"encounter": {
"reference": "Encounter/encounter-outpatient-001"
},
"effectiveDateTime": "2025-01-15T08:15:00+07:00",
"performer": [
{
"reference": "Practitioner/practitioner-002",
"display": "ĐD. Lê Thị C"
}
],
"component": [
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "8480-6",
"display": "Systolic blood pressure"
}
]
},
"valueQuantity": {
"value": 145,
"unit": "mmHg",
"system": "http://unitsofmeasure.org",
"code": "mm[Hg]"
},
"interpretation": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation",
"code": "H",
"display": "High"
}
]
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "8462-4",
"display": "Diastolic blood pressure"
}
]
},
"valueQuantity": {
"value": 92,
"unit": "mmHg",
"system": "http://unitsofmeasure.org",
"code": "mm[Hg]"
},
"interpretation": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation",
"code": "H",
"display": "High"
}
]
}
]
}
]
}
例如：實驗室結果 — HbA1c
{
"resourceType": "Observation",
"id": "obs-hba1c-001",
"status": "final",
"category": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
"code": "laboratory"
}
]
}
],
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "4548-4",
"display": "Hemoglobin A1c/Hemoglobin.total in Blood"
}
],
"text": "HbA1c"
},
"subject": {
"reference": "Patient/patient-001"
},
"effectiveDateTime": "2025-01-15",
"valueQuantity": {
"value": 7.2,
"unit": "%",
"system": "http://unitsofmeasure.org",
"code": "%"
},
"referenceRange": [
{
"low": {
"value": 4.0,
"unit": "%"
},
"high": {
"value": 5.6,
"unit": "%"
},
"text": "Bình thường: 4.0 - 5.6%"
}
],
"interpretation": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation",
"code": "H",
"display": "High"
}
],
"text": "Cao — Gợi ý đái tháo đường kiểm soát chưa tốt"
}
]
}
4. 透過參考文獻連結資源
Patient ──────────────────┐
│ │
▼ ▼
Encounter ──────────────▶ Condition
│ diagnosis │
│ │ evidence
▼ ▼
Observation ◀──────────── Observation
(vital signs) (lab results)
所有臨床資源透過以下方式連結在一起 參考。 Encounter 包含 Patient 的引用，Condition 透過元素附加到 Encounter 相遇。遭遇，觀察既指患者、遭遇，也可以指條件。
5. 總結
相遇 — 互動描述（門診、入院、急診室、遠距醫療）
條件 — 使用 ICD-10/SNOMED CT 診斷疾病、分期、嚴重程度
觀察 — 最靈活的資源：生命徵象 (LOINC)、實驗室結果、社會歷史
參考文獻 — 連結建立完整的臨床資料網絡