電子カルテ情報共有サービス2文書５情報+患者サマリー　FHIR実装ガイド JP-CLINS（CLinical Information Sharing ImplementationGuide） v1.5.4
1.5.4 - release Japan

電子カルテ情報共有サービス2文書５情報+患者サマリー　FHIR実装ガイド JP-CLINS（CLinical Information Sharing ImplementationGuide） v1.5.4 - Local Development build (v1.5.4) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Example Bundle: Bundle-CLINS-Referral-Example-01

Document Details

Generated Narrative: Bundle 診療情報提供書

Document Subject

Generated Narrative: Patient Example-JP-Patient-eCS-MAKINOInline

Last updated: 2021-11-26 10:00:00+0900; Language: ja

Profile: eCS/CLINS:JP_Patient_eCSversion: null1.5.4)

牧野 爛漫 Female, DoB: 1930-06-28 ( urn:oid:1.2.392.100495.20.3.51.11318814790#000999739)

Active:true
Other Ids:http://jpfhir.jp/fhir/clins/Idsystem/JP_Insurance_memberID/00012345:あいう:１８７:05
Alt. Name:マキノ ランマン
Contact Detail
  • ph: 03-123-1234(Home)
  • 高知県高知市五台山4200-6
Contact:
  • ph: 03-0123-4545 99991(Work)

Document Content

紹介元情報

港診療所

紹介先情報

東京第一テスト病院

構造情報

紹介目的

腹痛精査お願いします。

傷病名・主訴

上腹部痛、腰痛

現病歴

２０２２年６月上旬から夜食後に時々上腹部痛があり、だんだんひどくなっている。他に目立った症状なし。

既往歴

2018年　狭心症　２ヶ月治療で軽快。2019年　交通事故で左前腕骨折　３ヶ月ギプス固定。

アレルギー・不耐性反応

サバ　キーウイ　ヨード禁

家族歴

母　胃がん

身体所見

腹部所見：上腹部圧痛あり、その他特に所見なし。

感染症情報

特になし

臨床経過

添付参照

Additional Resources Included in Document

エントリ 1 - fullUrl = urn:uuid:830ec2d1-67a7-427e-b6fe-ad0eb29da7fb

Resource Composition:

Generated Narrative: Composition compositionReferralExample01Inline

Last updated: 2021-11-26 10:00:00+0900; Language: ja

Profile: JP_Composition_eReferralversion: null1.5.4)

Composition Version Number: 1.0

identifier: http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier/1311234567-2021-12345678

status: Final

type: 診療情報提供書

category: 外来文書

encounter: 受診Encounterリソース

date: 2020-08-21 12:12:20+0900

author:

title: 診療情報提供書

custodian: 診療情報提供書交付責任機関Organizationリソース

Events

-PeriodDetail
*2020-08-21 --> (ongoing)No display for Composition.event.detail (concept: )

エントリ 2 - fullUrl = urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd

Resource Patient:

Generated Narrative: Patient Example-JP-Patient-eCS-MAKINOInline

Last updated: 2021-11-26 10:00:00+0900; Language: ja

Profile: eCS/CLINS:JP_Patient_eCSversion: null1.5.4)

牧野 爛漫 Female, DoB: 1930-06-28 ( urn:oid:1.2.392.100495.20.3.51.11318814790#000999739)

Active:true
Other Ids:http://jpfhir.jp/fhir/clins/Idsystem/JP_Insurance_memberID/00012345:あいう:１８７:05
Alt. Name:マキノ ランマン
Contact Detail
  • ph: 03-123-1234(Home)
  • 高知県高知市五台山4200-6
Contact:
  • ph: 03-0123-4545 99991(Work)

エントリ 3 - fullUrl = urn:uuid:7cad1f19-3435-451d-9a71-a81b61f3358e

Resource Encounter:

Generated Narrative: Encounter Example-JP-Encounter-eCS-AMB-01Inline

Last updated: 2021-11-26 10:00:00+0900; Language: ja

Profile: eCS/CLINS:JP_Encounter-eCSversion: null1.5.4)

identifier: http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier/192844

status: completed

class: 外来

エントリ 4 - fullUrl = urn:uuid:3e6a0ba2-d781-4fd7-9de6-e077b690daed

Resource Practitioner:

Generated Narrative: Practitioner Example-JP-Practitioner-eCS-ReferralFrom01Inline

Last updated: 2021-11-26 10:00:00+0900; Language: ja

Profile: eCS/CLINS:JP_Practitioner_eCS

name: 大河内 勘三郎(Official), オオコウチ カンザブロウ(Official)

エントリ 5 - fullUrl = urn:uuid:f11535c2-043d-43b6-bf99-b8298ea3c946

Resource Practitioner:

Generated Narrative: Practitioner Example-JP-Practitioner-eCS-ReferralTo01Inline

Last updated: 2021-11-26 10:00:00+0900; Language: ja

Profile: eCS/CLINS:JP_Practitioner_eCS

name: 野口 英世丸(Official), ノグチ ヒデヨマル(Official)

エントリ 6 - fullUrl = urn:uuid:8a888471-9781-4fb7-b5c4-b34afcdea638

Resource Organization:

Generated Narrative: Organization Example-JP-Org-eCS-Inst-Referral01Inline

Last updated: 2021-11-26 10:00:00+0900; Language: ja

Profile: JP_Organization_eCS

JP Core Organization PrefectureNo Extension: JP Core PrefectureNumber CodeSystem 13: 東京都

JP Core Organization InsuranceOrganizationCategory Extension: JP Core MedicalFeeScoreType CodeSystem 1: 医科

JP Core Organization InsuranceOrganizationNo Extension: http://jpfhir.jp/fhir/core/mhlw/IdSystem/MedicalOrganizationID/9876543

JP eCS Department Extension: 眼科

identifier: http://jpfhir.jp/fhir/core/IdSystem/insurance-medical-institution-no/1319876543

type: Healthcare Provider

name: 港診療所

Contacts

-TelecomAddress
*ph: 03-9876-5432東京都港区新橋１−２−３

エントリ 7 - fullUrl = urn:uuid:a44951be-cdaa-4c53-9e35-6be013da5441

Resource Organization:

Generated Narrative: Organization Example-JP-Org-eCS-ReferralTo01Inline

Last updated: 2021-11-26 10:00:00+0900; Language: ja

Profile: JP_Organization_eCS

JP Core Organization PrefectureNo Extension: JP Core PrefectureNumber CodeSystem 13: 東京都

JP Core Organization InsuranceOrganizationCategory Extension: JP Core MedicalFeeScoreType CodeSystem 1: 医科

JP Core Organization InsuranceOrganizationNo Extension: http://jpfhir.jp/fhir/core/mhlw/IdSystem/MedicalOrganizationID/1234567

JP eCS Department Extension: 循環器内科

identifier: http://jpfhir.jp/fhir/core/IdSystem/insurance-medical-institution-no/1311234567

type: Healthcare Provider

name: 東京第一テスト病院

Contacts

-TelecomAddress
*ph: 03-1234-5678東京都文京区文京町１−２−３

エントリ 8 - fullUrl = urn:uuid:3acc3dc7-c79b-41f1-8eea-ac4de9b664b8

Resource Encounter:

Generated Narrative: Encounter Example-JP-Encounter-eCS-purpose-Referral01Inline

Last updated: 2021-11-26 10:00:00+0900; Language: ja

Profile: eCS/CLINS:JP_Encounter-eCSversion: null1.5.4)

identifier: http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier/192837

status: completed

class: 外来

エントリ 9 - fullUrl = urn:uuid:6a31db8e-109d-4349-b0cf-095131c3307a

Resource Condition:

Generated Narrative: Condition Example-JP-Condition-eCS-cc1-Referral01Inline

Last updated: 2021-11-26 10:00:00+0900; Language: ja

Profile: eCS/CLINS:JP_Condition_eCSversion: null1.5.4)

identifier: http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier/192837-01

clinicalStatus: Active

verificationStatus: Confirmed

category: Problem List Item

code: 上腹部痛

subject: Bundle: identifier = http://jpfhir.jp/fhir/clins/bundle-identifier#1318814790^2024^0123-PCS-203949583949; type = document; timestamp = 2024-07-07 10:00:00+0900

onset: 2022-06-09

エントリ 10 - fullUrl = urn:uuid:a9358f3e-c743-4998-aa89-1be54c31b432

Resource Condition:

Generated Narrative: Condition Example-JP-Condition-eCS-cc2-Referral01Inline

Last updated: 2021-11-26 10:00:00+0900

Profile: eCS/CLINS:JP_Condition_eCSversion: null1.5.4)

identifier: http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier/192837-02

clinicalStatus: Active

verificationStatus: Confirmed

category: Problem List Item

code: 腰痛

subject: Bundle: identifier = http://jpfhir.jp/fhir/clins/bundle-identifier#1318814790^2024^0123-PCS-203949583949; type = document; timestamp = 2024-07-07 10:00:00+0900

onset: 2022-05

エントリ 11 - fullUrl = urn:uuid:5eab50b2-6741-467c-a2fd-a4adab1f835f

Resource Condition:

Generated Narrative: Condition Example-JP-Condition-eCS-ABDPAINInline

Last updated: 2021-11-26 10:00:00+0900; Language: ja

Profile: eCS/CLINS:JP_Condition_eCSversion: null1.5.4)

JP eCS InstitutionNumber Extension: http://jpfhir.jp/fhir/core/IdSystem/insurance-medical-institution-no/1318814790

JP eCS Department Extension: 循環器診療科

identifier: http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier/192838

clinicalStatus: Active

verificationStatus: Confirmed

category: Encounter Diagnosis

code: 上腹部痛

subject: Bundle: identifier = http://jpfhir.jp/fhir/clins/bundle-identifier#1318814790^2024^0123-PCS-203949583949; type = document; timestamp = 2024-07-07 10:00:00+0900

encounter: Encounter: identifier = http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier#192844; status = completed; class = 外来

note: ２０２２年６月上旬から夜食後に時々上腹部痛があり、だんだんひどくなっている。他に目立った症状なし。

Generated Narrative: Encounter #Example-Contained-JP-Encounter-AMB

Language: ja

Profile: JP Core Encounter Profile

identifier: http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier/192844

status: completed

class: 外来

エントリ 12 - fullUrl = urn:uuid:5c650562-f4e4-40b3-87c6-e9a0376be7a8

Resource Condition:

Generated Narrative: Condition Example-JP-Condition-eCS-ANGINAInline

Last updated: 2021-11-26 10:00:00+0900; Language: ja

Profile: eCS/CLINS:JP_Condition_eCSversion: null1.5.4)

identifier: http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier/192839-01

clinicalStatus: Resolved

verificationStatus: Confirmed

category: Encounter Diagnosis

code: 狭心症

subject: Bundle: identifier = http://jpfhir.jp/fhir/clins/bundle-identifier#1318814790^2024^0123-PCS-203949583949; type = document; timestamp = 2024-07-07 10:00:00+0900

onset: 2018

note: 2018年　狭心症　２ヶ月治療で軽快。

エントリ 13 - fullUrl = urn:uuid:a28198b9-6a23-4677-ba2e-5eb3e17d9792

Resource Condition:

Generated Narrative: Condition Example-JP-Condition-eCS-FxInline

Last updated: 2021-11-26 10:00:00+0900; Language: ja

Profile: eCS/CLINS:JP_Condition_eCSversion: null1.5.4)

identifier: http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier/192839-02

clinicalStatus: Resolved

verificationStatus: Confirmed

category: Encounter Diagnosis

code: 左前腕骨折

subject: Bundle: identifier = http://jpfhir.jp/fhir/clins/bundle-identifier#1318814790^2024^0123-PCS-203949583949; type = document; timestamp = 2024-07-07 10:00:00+0900

onset: 2021

note: 交通事故で左前腕骨折　３ヶ月ギプス固定。

エントリ 14 - fullUrl = urn:uuid:711b07ae-d20b-40b0-9aa9-c7f1981409e6

Resource AllergyIntolerance:

アレルギー: さば

エントリ 15 - fullUrl = urn:uuid:5a1aae74-f720-415a-ba15-a6c8b5d4c5a1

Resource AllergyIntolerance:

アレルギー:キーウイ

発症:2020-04-10 情報源：本人　記録：2024-07-10　記録者：看護師A

エントリ 16 - fullUrl = urn:uuid:0d51bf2a-4863-b36f-2ad3-cb5ea0df1023

Resource AllergyIntolerance:

ポビドンヨード含嗽後に嘔吐と全身に発疹

エントリ 17 - fullUrl = urn:uuid:481835ef-0891-45de-a006-087954ab6b7c

Resource Observation:

Generated Narrative: Observation psExample-JP-Obs-Common-eCS-textOnly01Inline

Last updated: 2021-11-26 10:00:00+0900; Language: ja

Profile: JP_Observation_Common_eCS

identifier: http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier/192837

status: Final

category: Exam

code: 腹部所見

subject: Bundle: identifier = http://jpfhir.jp/fhir/clins/bundle-identifier#1318814790^2024^0123-PCS-203949583949; type = document; timestamp = 2024-07-07 10:00:00+0900

effective: 2021-07-05 11:19:41+0900

performer: Practitioner 田中 宏

value: 上腹部圧痛あり、その他特に所見なし。

Generated Narrative: Practitioner #Example-Contained-JP-Practitioner-minimun-D002

Language: ja

Profile: JP Core Practitioner Profile

identifier: urn:oid:1.2.392.100495.20.3.41.11311234567/D001

name: 田中 宏

エントリ 18 - fullUrl = urn:uuid:a6e4fc73-a749-4583-94a7-18e4241b4c75

Resource DocumentReference:

Generated Narrative: DocumentReference Example-JP-DocRef-eCS-clinical-ccourse-Referral01Inline

Last updated: 2023-03-31 00:00:00+0900; Language: ja

Profile: JP_DocumentReference_eCS

status: Current

type: Progress note

description:

臨床経過

content

Attachments

-ContentTypeUrl
*application/pdffile:///clinicalCourseExampleData.pdf