Bundle-CLINS-Referral-Example-01 - 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） v1.5.5 v1.5.5

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） v1.5.5 - Local Development build (v1.5.5) 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

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

Profile: JP_Bundle_eReferralversion: null1.5.5)

Final Document at 2020-08-21 12:12:20+0900 by 診療情報提供書作成者PractitionerRoleリソース, 診療情報提供書作成機関Organizationリソース for 患者リソースPatient in encounter 受診Encounterリソース

Document Subject

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

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

Profile: JP_Patient_eCSversion: null1.5.5)

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: null1.5.5)
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:
診療情報提供書作成者PractitionerRoleリソース
診療情報提供書作成機関Organizationリソース
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
- Period Detail
* 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: JP_Patient_eCSversion: null1.5.5)
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: JP_Encounter-eCSversion: null1.5.5)
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: 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: 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
- Telecom Address
* 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
- Telecom Address
* 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: JP_Encounter-eCSversion: null1.5.5)
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: JP_Condition_eCSversion: null1.5.5)
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: JP_Condition_eCSversion: null1.5.5)
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: JP_Condition_eCSversion: null1.5.5)
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: JP_Condition_eCSversion: null1.5.5)
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: JP_Condition_eCSversion: null1.5.5)
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
- ContentType Url
* application/pdf file:///clinicalCourseExampleData.pdf