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） v1.3.0-rc3 (リリース候補v3)
1.3.0-rc3 - 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） v1.3.0-rc3 (リリース候補v3) - Local Development build (v1.3.0-rc3) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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

Anonymous Patient Female, DoB: 1930-06-28 ( urn:oid:1.2.392.100495.20.3.51.11318814790#000999739)

Generated Narrative: Composition

ResourceComposition "compositionReferralExample01Inline" Updated"2021-11-26 10:00:00+0900" (Language"ja")

Profile: JP_Composition_eReferral

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 (FHIR文書の文書区分（医療文書全般）#57133-1)

category: 外来文書 (FHIR文書の文書サブ区分（医療文書全般）#OUTPATIENT)

encounter: See on this page: urn:uuid:7cad1f19-3435-451d-9a71-a81b61f3358e: 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: See on this page: urn:uuid:8a888471-9781-4fb7-b5c4-b34afcdea638: 診療情報提供書交付責任機関Organizationリソース

Events

-PeriodDetail
*2020-08-21 --> (ongoing)診療情報提供書発行 ()

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

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 Document Content

2. urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd (Patient/Example-JP-Patient-eCS-MAKINOInline)

Anonymous Patient Female, DoB: 1930-06-28 ( urn:oid:1.2.392.100495.20.3.51.11318814790#000999739)

3. urn:uuid:7cad1f19-3435-451d-9a71-a81b61f3358e (Encounter/Example-JP-Encounter-eCS-AMB-01Inline)

Not done yet

4. urn:uuid:3e6a0ba2-d781-4fd7-9de6-e077b690daed (Practitioner/Example-JP-Practitioner-eCS-ReferralFrom01Inline)

Generated Narrative: Practitioner

ResourcePractitioner "Example-JP-Practitioner-eCS-ReferralFrom01Inline" 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)

5. urn:uuid:f11535c2-043d-43b6-bf99-b8298ea3c946 (Practitioner/Example-JP-Practitioner-eCS-ReferralTo01Inline)

Generated Narrative: Practitioner

ResourcePractitioner "Example-JP-Practitioner-eCS-ReferralTo01Inline" 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)

6. urn:uuid:8a888471-9781-4fb7-b5c4-b34afcdea638 (Organization/Example-JP-Org-eCS-Inst-Referral01Inline)

Generated Narrative: Organization

ResourceOrganization "Example-JP-Org-eCS-Inst-Referral01Inline" Updated"2021-11-26 10:00:00+0900" (Language"ja")

Profile: JP_Organization_eCS

JP Core Organization PrefectureNo Extension: 東京都 (Details: JP Core PrefectureNumber CodeSystem code 13 = ' 東京都 ', stated as ' null ')

JP Core Organization InsuranceOrganizationCategory Extension: 医科 (Details: JP Core MedicalFeeScoreType CodeSystem code 1 = ' 医科 ', stated as ' null ')

JP Core Organization InsuranceOrganizationNo Extension: urn:oid:1.2.392.100495.20.3.23/9876543

JP eCS Department Extension: 眼科 (JP Core Department SS-MIX CodeSystem#26)

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

type: Healthcare Provider (Organization type#prov)

name: 港診療所

Contacts

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

7. urn:uuid:a44951be-cdaa-4c53-9e35-6be013da5441 (Organization/Example-JP-Org-eCS-ReferralTo01Inline)

Generated Narrative: Organization

ResourceOrganization "Example-JP-Org-eCS-ReferralTo01Inline" Updated"2021-11-26 10:00:00+0900" (Language"ja")

Profile: JP_Organization_eCS

JP Core Organization PrefectureNo Extension: 東京都 (Details: JP Core PrefectureNumber CodeSystem code 13 = ' 東京都 ', stated as ' null ')

JP Core Organization InsuranceOrganizationCategory Extension: 医科 (Details: JP Core MedicalFeeScoreType CodeSystem code 1 = ' 医科 ', stated as ' null ')

JP Core Organization InsuranceOrganizationNo Extension: urn:oid:1.2.392.100495.20.3.23/1234567

JP eCS Department Extension: 循環器内科 (JP Core Department SS-MIX CodeSystem#081)

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

type: Healthcare Provider (Organization type#prov)

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

8. urn:uuid:3acc3dc7-c79b-41f1-8eea-ac4de9b664b8 (Encounter/Example-JP-Encounter-eCS-purpose-Referral01Inline)

Not done yet

9. urn:uuid:6a31db8e-109d-4349-b0cf-095131c3307a (Condition/Example-JP-Condition-eCS-cc1-Referral01Inline)

Generated Narrative: Condition

ResourceCondition "Example-JP-Condition-eCS-cc1-Referral01Inline" Updated"2021-11-26 10:00:00+0900" (Language"ja")

Profile: eCS/CLINS:JP_Condition_eCS

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

clinicalStatus: Active (Condition Clinical Status Codes#active)

verificationStatus: Confirmed (ConditionVerificationStatus#confirmed)

category: Problem List Item (Condition Category Codes#problem-list-item)

code: 上腹部痛 ()

subject: See on this page: urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd

onset: 2022-06-09

10. urn:uuid:a9358f3e-c743-4998-aa89-1be54c31b432 (Condition/Example-JP-Condition-eCS-cc2-Referral01Inline)

Generated Narrative: Condition

ResourceCondition "Example-JP-Condition-eCS-cc2-Referral01Inline" Updated"2021-11-26 10:00:00+0900"

Profile: eCS/CLINS:JP_Condition_eCS

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

clinicalStatus: Active (Condition Clinical Status Codes#active)

verificationStatus: Confirmed (ConditionVerificationStatus#confirmed)

category: Problem List Item (Condition Category Codes#problem-list-item)

code: 腰痛 ()

subject: See on this page: urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd

onset: 2022-05

11. urn:uuid:5eab50b2-6741-467c-a2fd-a4adab1f835f (Condition/Example-JP-Condition-eCS-ABDPAINInline)

Generated Narrative: Condition

ResourceCondition "Example-JP-Condition-eCS-ABDPAINInline" Updated"2021-11-26 10:00:00+0900" (Language"ja")

Profile: eCS/CLINS:JP_Condition_eCS

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 (JP Core Department SS-MIX CodeSystem#08 "循環器科")

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

clinicalStatus: Active (Condition Clinical Status Codes#active)

verificationStatus: Confirmed (ConditionVerificationStatus#confirmed)

category: Encounter Diagnosis (Condition Category Codes#encounter-diagnosis)

code: 上腹部痛 ()

subject: See on this page: urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd

encounter:

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

status: COMPLETED

class: 外来 (ActCode#AMB)

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

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

status: COMPLETED

class: 外来 (ActCode#AMB)

12. urn:uuid:5c650562-f4e4-40b3-87c6-e9a0376be7a8 (Condition/Example-JP-Condition-eCS-ANGINAInline)

Generated Narrative: Condition

ResourceCondition "Example-JP-Condition-eCS-ANGINAInline" Updated"2021-11-26 10:00:00+0900" (Language"ja")

Profile: eCS/CLINS:JP_Condition_eCS

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

clinicalStatus: Resolved (Condition Clinical Status Codes#resolved)

verificationStatus: Confirmed (ConditionVerificationStatus#confirmed)

category: Encounter Diagnosis (Condition Category Codes#encounter-diagnosis)

code: 狭心症 ()

subject: See on this page: urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd

onset: 2018

note: 2018年　狭心症　２ヶ月治療で軽快。

13. urn:uuid:a28198b9-6a23-4677-ba2e-5eb3e17d9792 (Condition/Example-JP-Condition-eCS-FxInline)

Generated Narrative: Condition

ResourceCondition "Example-JP-Condition-eCS-FxInline" Updated"2021-11-26 10:00:00+0900" (Language"ja")

Profile: eCS/CLINS:JP_Condition_eCS

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

clinicalStatus: Resolved (Condition Clinical Status Codes#resolved)

verificationStatus: Confirmed (ConditionVerificationStatus#confirmed)

category: Encounter Diagnosis (Condition Category Codes#encounter-diagnosis)

code: 左前腕骨折 ()

subject: See on this page: urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd

onset: 2021

note: 交通事故で左前腕骨折　３ヶ月ギプス固定。

14. urn:uuid:711b07ae-d20b-40b0-9aa9-c7f1981409e6 (AllergyIntolerance/Example-JP-Allergy-eCS-01Inline)

Generated Narrative: AllergyIntolerance

ResourceAllergyIntolerance "Example-JP-Allergy-eCS-01Inline" Updated"2021-11-26 10:00:00+0900" (Language"ja")

Profile: eCS/CLINS:JP_AllergyIntolerance_eCS

identifier: http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier/102934701

clinicalStatus: Active (AllergyIntolerance Clinical Status Codes#active)

type: Allergy (AllergyIntoleranceType#allergy)

category: FOOD

criticality: UNABLETOASSESS

code: サバ ()

patient: See on this page: urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd

encounter: See on this page: urn:uuid:7cad1f19-3435-451d-9a71-a81b61f3358e

onset: 30 a (Details: UCUM codea = 'a')

note: サバ食後３時間ほどで全身に発疹と腹痛あり

15. urn:uuid:5a1aae74-f720-415a-ba15-a6c8b5d4c5a1 (AllergyIntolerance/Example-JP-Allergy-eCS-02Inline)

Generated Narrative: AllergyIntolerance

ResourceAllergyIntolerance "Example-JP-Allergy-eCS-02Inline" Updated"2021-11-26 10:00:00+0900"

Profile: eCS/CLINS:JP_AllergyIntolerance_eCS

identifier: http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier/102934701

clinicalStatus: Active (AllergyIntolerance Clinical Status Codes#active)

type: Allergy (AllergyIntoleranceType#allergy)

category: FOOD

criticality: UNABLETOASSESS

code: キーウイ ()

patient: See on this page: urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd

encounter: See on this page: urn:uuid:7cad1f19-3435-451d-9a71-a81b61f3358e

onset: 10 a (Details: UCUM codea = 'a')

note: 食べると口の周りが痺れる感じ

16. urn:uuid:481835ef-0891-45de-a006-087954ab6b7c (Observation/psExample-JP-Obs-Common-eCS-textOnly01Inline)

Generated Narrative: Observation

ResourceObservation "psExample-JP-Obs-Common-eCS-textOnly01Inline" 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 (JP Core Simple Observation Category CodeSystem#exam)

code: 腹部所見 ()

subject: See on this page: urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd

value: 上腹部圧痛あり、その他特に所見なし。

17. urn:uuid:a6e4fc73-a749-4583-94a7-18e4241b4c75 (DocumentReference/Example-JP-DocRef-eCS-clinical-ccourse-Referral01Inline)

Generated Narrative: DocumentReference

ResourceDocumentReference "Example-JP-DocRef-eCS-clinical-ccourse-Referral01Inline" Updated"2023-03-31 00:00:00+0900" (Language"ja")

Profile: JP_DocumentReference_eCS

status: CURRENT

type: Progress note (LOINC#11506-3)

description: 臨床経過

content

Attachments

-ContentTypeUrl
*text/plain;charset=UTF-8test.pdf