{ "resourceType" : "Bundle", "id" : "Bundle-CLINS-Referral-Example-01", "meta" : { "lastUpdated" : "2021-11-26T10:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/clins/StructureDefinition/JP_Bundle_eReferral|1.6.0"] }, "language" : "ja", "identifier" : { "system" : "http://jpfhir.jp/fhir/clins/bundle-identifier", "value" : "1318814790^2024^0123-Referral-203949583949" }, "type" : "document", "timestamp" : "2021-11-26T10:00:00+09:00", "entry" : [{ "fullUrl" : "urn:uuid:830ec2d1-67a7-427e-b6fe-ad0eb29da7fb", "resource" : { "resourceType" : "Composition", "id" : "compositionReferralExample01Inline", "meta" : { "lastUpdated" : "2021-11-26T10:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/eReferral/StructureDefinition/JP_Composition_eReferral|1.6.0"] }, "language" : "ja", "text" : { "status" : "extensions", "div" : "

Generated Narrative: Composition compositionReferralExample01Inline

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

Profile: JP_Composition_eReferralversion: null1.6.0)

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

-CodePeriod
*診療情報提供書発行2020-08-21 --> (ongoing)
" }, "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString" : "1.0" }], "identifier" : { "system" : "http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier", "value" : "1311234567-2021-12345678" }, "status" : "final", "type" : { "coding" : [{ "system" : "http://jpfhir.jp/fhir/Common/CodeSystem/doc-typecodes", "code" : "57133-1", "display" : "診療情報提供書" }] }, "category" : [{ "coding" : [{ "system" : "http://jpfhir.jp/fhir/Common/CodeSystem/doc-subtypecodes", "code" : "OUTPATIENT", "display" : "外来文書" }] }], "subject" : { "reference" : "urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd", "type" : "Patient", "display" : "患者リソースPatient" }, "encounter" : { "reference" : "urn:uuid:7cad1f19-3435-451d-9a71-a81b61f3358e", "type" : "Encounter", "display" : "受診Encounterリソース" }, "date" : "2020-08-21T12:12:20+09:00", "author" : [{ "reference" : "urn:uuid:3e6a0ba2-d781-4fd7-9de6-e077b690daed", "type" : "Practitioner", "display" : "診療情報提供書作成者PractitionerRoleリソース" }, { "reference" : "urn:uuid:8a888471-9781-4fb7-b5c4-b34afcdea638", "type" : "Organization", "display" : "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" : { "reference" : "urn:uuid:8a888471-9781-4fb7-b5c4-b34afcdea638", "type" : "Organization", "display" : "診療情報提供書交付責任機関Organizationリソース" }, "event" : [{ "code" : [{ "text" : "診療情報提供書発行" }], "period" : { "start" : "2020-08-21" } }], "section" : [{ "title" : "紹介元情報", "code" : { "coding" : [{ "system" : "http://jpfhir.jp/fhir/clins/CodeSystem/document-section", "code" : "920", "display" : "紹介元情報セクション" }] }, "text" : { "status" : "additional", "div" : "
港診療所
" }, "entry" : [{ "reference" : "urn:uuid:8a888471-9781-4fb7-b5c4-b34afcdea638", "type" : "Organization", "display" : "紹介元医療機関" }, { "reference" : "urn:uuid:3e6a0ba2-d781-4fd7-9de6-e077b690daed", "type" : "Practitioner", "display" : "紹介元医師" }] }, { "title" : "紹介先情報", "code" : { "coding" : [{ "system" : "http://jpfhir.jp/fhir/clins/CodeSystem/document-section", "code" : "910", "display" : "紹介先情報セクション" }] }, "text" : { "status" : "additional", "div" : "
東京第一テスト病院
" }, "entry" : [{ "reference" : "urn:uuid:a44951be-cdaa-4c53-9e35-6be013da5441", "type" : "Organization", "display" : "紹介先医療機関" }, { "reference" : "urn:uuid:f11535c2-043d-43b6-bf99-b8298ea3c946", "type" : "Practitioner", "display" : "紹介先医師" }] }, { "title" : "構造情報", "code" : { "coding" : [{ "system" : "http://jpfhir.jp/fhir/clins/CodeSystem/document-section", "code" : "300", "display" : "構造情報セクション" }] }, "section" : [{ "title" : "紹介目的", "code" : { "coding" : [{ "system" : "http://jpfhir.jp/fhir/clins/CodeSystem/document-section", "code" : "950", "display" : "紹介目的セクション" }] }, "text" : { "status" : "additional", "div" : "
腹痛精査お願いします。
" }, "entry" : [{ "reference" : "urn:uuid:3acc3dc7-c79b-41f1-8eea-ac4de9b664b8", "type" : "Encounter", "display" : "紹介目的" }] }, { "title" : "傷病名・主訴", "code" : { "coding" : [{ "system" : "http://jpfhir.jp/fhir/clins/CodeSystem/document-section", "code" : "340", "display" : "傷病名・主訴セクション" }] }, "text" : { "status" : "additional", "div" : "
上腹部痛、腰痛
" }, "entry" : [{ "reference" : "urn:uuid:6a31db8e-109d-4349-b0cf-095131c3307a", "type" : "Condition", "display" : "傷病名・主訴" }, { "reference" : "urn:uuid:a9358f3e-c743-4998-aa89-1be54c31b432", "type" : "Condition", "display" : "傷病名・主訴" }] }, { "title" : "現病歴", "code" : { "coding" : [{ "system" : "http://jpfhir.jp/fhir/clins/CodeSystem/document-section", "code" : "360", "display" : "現病歴セクション" }] }, "text" : { "status" : "additional", "div" : "
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。
" }, "entry" : [{ "reference" : "urn:uuid:5eab50b2-6741-467c-a2fd-a4adab1f835f", "type" : "Condition", "display" : "現病歴" }] }, { "title" : "既往歴", "code" : { "coding" : [{ "system" : "http://jpfhir.jp/fhir/clins/CodeSystem/document-section", "code" : "370", "display" : "既往歴セクション" }] }, "text" : { "status" : "additional", "div" : "
2018年\u3000狭心症\u3000２ヶ月治療で軽快。2019年\u3000交通事故で左前腕骨折\u3000３ヶ月ギプス固定。
" }, "entry" : [{ "reference" : "urn:uuid:5c650562-f4e4-40b3-87c6-e9a0376be7a8", "type" : "Condition", "display" : "既往歴" }, { "reference" : "urn:uuid:a28198b9-6a23-4677-ba2e-5eb3e17d9792", "type" : "Condition", "display" : "既往歴" }] }, { "title" : "アレルギー・不耐性反応", "code" : { "coding" : [{ "system" : "http://jpfhir.jp/fhir/clins/CodeSystem/document-section", "code" : "510", "display" : "アレルギー・不耐性反応セクション" }] }, "text" : { "status" : "additional", "div" : "
サバ\u3000キーウイ\u3000ヨード禁
" }, "entry" : [{ "reference" : "urn:uuid:711b07ae-d20b-40b0-9aa9-c7f1981409e6", "type" : "AllergyIntolerance", "display" : "アレルギー・不耐性反応" }, { "reference" : "urn:uuid:5a1aae74-f720-415a-ba15-a6c8b5d4c5a1", "type" : "AllergyIntolerance", "display" : "アレルギー・不耐性反応" }, { "reference" : "urn:uuid:0d51bf2a-4863-b36f-2ad3-cb5ea0df1023", "type" : "AllergyIntolerance", "display" : "アレルギー・不耐性反応" }] }, { "title" : "家族歴", "code" : { "coding" : [{ "system" : "http://jpfhir.jp/fhir/clins/CodeSystem/document-section", "code" : "550", "display" : "家族歴セクション" }] }, "text" : { "status" : "additional", "div" : "
母\u3000胃がん
" } }, { "title" : "身体所見", "code" : { "coding" : [{ "system" : "http://jpfhir.jp/fhir/clins/CodeSystem/document-section", "code" : "610", "display" : "身体所見セクション" }] }, "text" : { "status" : "additional", "div" : "
腹部所見：上腹部圧痛あり、その他特に所見なし。
" }, "entry" : [{ "reference" : "urn:uuid:481835ef-0891-45de-a006-087954ab6b7c", "type" : "Observation", "display" : "身体所見" }] }, { "title" : "感染症情報", "code" : { "coding" : [{ "system" : "http://jpfhir.jp/fhir/clins/CodeSystem/document-section", "code" : "520", "display" : "感染症情報セクション" }] }, "text" : { "status" : "additional", "div" : "
特になし
" } }, { "title" : "臨床経過", "code" : { "coding" : [{ "system" : "http://jpfhir.jp/fhir/clins/CodeSystem/document-section", "code" : "330", "display" : "臨床経過セクション" }] }, "text" : { "status" : "additional", "div" : "
添付参照
" }, "entry" : [{ "reference" : "urn:uuid:a6e4fc73-a749-4583-94a7-18e4241b4c75", "type" : "DocumentReference", "display" : "臨床経過" }] }] }] } }, { "fullUrl" : "urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd", "resource" : { "resourceType" : "Patient", "id" : "Example-JP-Patient-eCS-MAKINOInline", "meta" : { "lastUpdated" : "2021-11-26T10:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/eCS/StructureDefinition/JP_Patient_eCS|1.6.0"] }, "language" : "ja", "text" : { "status" : "generated", "div" : "

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

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

Profile: JP_Patient_eCSversion: null1.6.0)

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)
" }, "identifier" : [{ "system" : "urn:oid:1.2.392.100495.20.3.51.11318814790", "value" : "000999739" }, { "system" : "http://jpfhir.jp/fhir/clins/Idsystem/JP_Insurance_memberID", "value" : "00012345:あいう:１８７:05" }], "active" : true, "name" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/iso21090-EN-representation", "valueCode" : "IDE" }], "text" : "牧野 爛漫", "family" : "牧野", "given" : ["爛漫"] }, { "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/iso21090-EN-representation", "valueCode" : "SYL" }], "text" : "マキノ ランマン", "family" : "マキノ", "given" : ["ランマン"] }], "telecom" : [{ "system" : "phone", "value" : "03-123-1234", "use" : "home", "rank" : 1 }], "gender" : "female", "birthDate" : "1930-06-28", "address" : [{ "text" : "高知県高知市五台山4200-6", "city" : "高知市", "state" : "高知県", "postalCode" : "781-8125" }], "contact" : [{ "telecom" : [{ "system" : "phone", "value" : "03-0123-4545 99991", "use" : "work", "rank" : 2 }] }] } }, { "fullUrl" : "urn:uuid:7cad1f19-3435-451d-9a71-a81b61f3358e", "resource" : { "resourceType" : "Encounter", "id" : "Example-JP-Encounter-eCS-AMB-01Inline", "meta" : { "lastUpdated" : "2021-11-26T10:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/eCS/StructureDefinition/JP_Encounter_eCS|1.6.0"] }, "language" : "ja", "text" : { "status" : "generated", "div" : "

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

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

Profile: JP_Encounter-eCSversion: null1.6.0)

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

status: Finished

class: ActCode AMB: 外来

ClassHistories

-ClassPeriod
*ActCode AMB: 外来2020-08-20 --> (ongoing)
" }, "identifier" : [{ "system" : "http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier", "value" : "192844" }], "status" : "finished", "class" : { "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code" : "AMB", "display" : "外来" }, "classHistory" : [{ "class" : { "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code" : "AMB", "display" : "外来" }, "period" : { "start" : "2020-08-20" } }] } }, { "fullUrl" : "urn:uuid:3e6a0ba2-d781-4fd7-9de6-e077b690daed", "resource" : { "resourceType" : "Practitioner", "id" : "Example-JP-Practitioner-eCS-ReferralFrom01Inline", "meta" : { "lastUpdated" : "2021-11-26T10:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/eCS/StructureDefinition/JP_Practitioner_eCS"] }, "language" : "ja", "text" : { "status" : "generated", "div" : "

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)

" }, "name" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/iso21090-EN-representation", "valueCode" : "IDE" }], "use" : "official", "text" : "大河内 勘三郎", "family" : "大河内", "given" : ["勘三郎"] }, { "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/iso21090-EN-representation", "valueCode" : "SYL" }], "use" : "official", "text" : "オオコウチ カンザブロウ", "family" : "オオコウチ", "given" : ["カンザブロウ"] }] } }, { "fullUrl" : "urn:uuid:f11535c2-043d-43b6-bf99-b8298ea3c946", "resource" : { "resourceType" : "Practitioner", "id" : "Example-JP-Practitioner-eCS-ReferralTo01Inline", "meta" : { "lastUpdated" : "2021-11-26T10:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/eCS/StructureDefinition/JP_Practitioner_eCS"] }, "language" : "ja", "text" : { "status" : "generated", "div" : "

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)

" }, "name" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/iso21090-EN-representation", "valueCode" : "IDE" }], "use" : "official", "text" : "野口 英世丸", "family" : "野口", "given" : ["英世丸"] }, { "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/iso21090-EN-representation", "valueCode" : "SYL" }], "use" : "official", "text" : "ノグチ ヒデヨマル", "family" : "ノグチ", "given" : ["ヒデヨマル"] }] } }, { "fullUrl" : "urn:uuid:8a888471-9781-4fb7-b5c4-b34afcdea638", "resource" : { "resourceType" : "Organization", "id" : "Example-JP-Org-eCS-Inst-Referral01Inline", "meta" : { "lastUpdated" : "2021-11-26T10:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/eCS/StructureDefinition/JP_Organization_eCS"] }, "language" : "ja", "text" : { "status" : "extensions", "div" : "

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

telecom: ph: 03-9876-5432

address: 東京都港区新橋１−２−３

" }, "extension" : [{ "url" : "http://jpfhir.jp/fhir/core/Extension/StructureDefinition/JP_Organization_PrefectureNo", "valueCoding" : { "system" : "http://jpfhir.jp/fhir/core/mhlw/CodeSystem/PrefectureNo-2digits", "code" : "13" } }, { "url" : "http://jpfhir.jp/fhir/core/Extension/StructureDefinition/JP_Organization_InsuranceOrganizationCategory", "valueCoding" : { "system" : "http://jpfhir.jp/fhir/core/mhlw/CodeSystem/MedicationFeeScoreType", "code" : "1" } }, { "url" : "http://jpfhir.jp/fhir/core/Extension/StructureDefinition/JP_Organization_InsuranceOrganizationNo", "valueIdentifier" : { "system" : "http://jpfhir.jp/fhir/core/mhlw/IdSystem/MedicalOrganizationID", "value" : "9876543" } }, { "url" : "http://jpfhir.jp/fhir/eCS/Extension/StructureDefinition/JP_eCS_Department", "valueCodeableConcept" : { "coding" : [{ "system" : "http://jami.jp/SS-MIX2/CodeSystem/ClinicalDepartment", "code" : "26", "display" : "眼科" }] } }], "identifier" : [{ "system" : "http://jpfhir.jp/fhir/core/IdSystem/insurance-medical-institution-no", "value" : "1319876543" }], "type" : [{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/organization-type", "code" : "prov" }] }], "name" : "港診療所", "telecom" : [{ "system" : "phone", "value" : "03-9876-5432" }], "address" : [{ "text" : "東京都港区新橋１−２−３", "postalCode" : "106-9900", "country" : "JP" }] } }, { "fullUrl" : "urn:uuid:a44951be-cdaa-4c53-9e35-6be013da5441", "resource" : { "resourceType" : "Organization", "id" : "Example-JP-Org-eCS-ReferralTo01Inline", "meta" : { "lastUpdated" : "2021-11-26T10:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/eCS/StructureDefinition/JP_Organization_eCS"] }, "language" : "ja", "text" : { "status" : "extensions", "div" : "

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

telecom: ph: 03-1234-5678

address: 東京都文京区文京町１−２−３

" }, "extension" : [{ "url" : "http://jpfhir.jp/fhir/core/Extension/StructureDefinition/JP_Organization_PrefectureNo", "valueCoding" : { "system" : "http://jpfhir.jp/fhir/core/mhlw/CodeSystem/PrefectureNo-2digits", "code" : "13" } }, { "url" : "http://jpfhir.jp/fhir/core/Extension/StructureDefinition/JP_Organization_InsuranceOrganizationCategory", "valueCoding" : { "system" : "http://jpfhir.jp/fhir/core/mhlw/CodeSystem/MedicationFeeScoreType", "code" : "1" } }, { "url" : "http://jpfhir.jp/fhir/core/Extension/StructureDefinition/JP_Organization_InsuranceOrganizationNo", "valueIdentifier" : { "system" : "http://jpfhir.jp/fhir/core/mhlw/IdSystem/MedicalOrganizationID", "value" : "1234567" } }, { "url" : "http://jpfhir.jp/fhir/eCS/Extension/StructureDefinition/JP_eCS_Department", "valueCodeableConcept" : { "coding" : [{ "system" : "http://jami.jp/SS-MIX2/CodeSystem/ClinicalDepartment", "code" : "081", "display" : "循環器内科" }] } }], "identifier" : [{ "system" : "http://jpfhir.jp/fhir/core/IdSystem/insurance-medical-institution-no", "value" : "1311234567" }], "type" : [{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/organization-type", "code" : "prov" }] }], "name" : "東京第一テスト病院", "telecom" : [{ "system" : "phone", "value" : "03-1234-5678" }], "address" : [{ "text" : "東京都文京区文京町１−２−３", "postalCode" : "113-0001", "country" : "JP" }] } }, { "fullUrl" : "urn:uuid:3acc3dc7-c79b-41f1-8eea-ac4de9b664b8", "resource" : { "resourceType" : "Encounter", "id" : "Example-JP-Encounter-eCS-purpose-Referral01Inline", "meta" : { "lastUpdated" : "2021-11-26T10:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/eCS/StructureDefinition/JP_Encounter_eCS|1.6.0"] }, "language" : "ja", "text" : { "status" : "generated", "div" : "

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

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

Profile: JP_Encounter-eCSversion: null1.6.0)

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

status: Finished

class: ActCode AMB: 外来

reasonCode: 腹痛精査お願いします。

" }, "identifier" : [{ "system" : "http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier", "value" : "192837" }], "status" : "finished", "class" : { "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code" : "AMB", "display" : "外来" }, "reasonCode" : [{ "text" : "腹痛精査お願いします。" }] } }, { "fullUrl" : "urn:uuid:6a31db8e-109d-4349-b0cf-095131c3307a", "resource" : { "resourceType" : "Condition", "id" : "Example-JP-Condition-eCS-cc1-Referral01Inline", "meta" : { "lastUpdated" : "2021-11-26T10:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/eCS/StructureDefinition/JP_Condition_eCS|1.6.0"] }, "language" : "ja", "text" : { "status" : "generated", "div" : "

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

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

Profile: JP_Condition_eCSversion: null1.6.0)

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

" }, "identifier" : [{ "system" : "http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier", "value" : "192837-01" }], "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" : "problem-list-item" }] }], "code" : { "coding" : [{ "system" : "http://medis.or.jp/CodeSystem/master-disease-keyNumber", "code" : "20065011", "display" : "上腹部痛" }], "text" : "上腹部痛" }, "subject" : { "reference" : "urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd" }, "onsetDateTime" : "2022-06-09" } }, { "fullUrl" : "urn:uuid:a9358f3e-c743-4998-aa89-1be54c31b432", "resource" : { "resourceType" : "Condition", "id" : "Example-JP-Condition-eCS-cc2-Referral01Inline", "meta" : { "lastUpdated" : "2021-11-26T10:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/eCS/StructureDefinition/JP_Condition_eCS|1.6.0"] }, "text" : { "status" : "generated", "div" : "

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

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

Profile: JP_Condition_eCSversion: null1.6.0)

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

" }, "identifier" : [{ "system" : "http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier", "value" : "192837-02" }], "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" : "problem-list-item" }] }], "code" : { "coding" : [{ "system" : "http://medis.or.jp/CodeSystem/master-disease-keyNumber", "code" : "20075383", "display" : "腹痛症" }], "text" : "腰痛" }, "subject" : { "reference" : "urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd" }, "onsetDateTime" : "2022-05" } }, { "fullUrl" : "urn:uuid:5eab50b2-6741-467c-a2fd-a4adab1f835f", "resource" : { "resourceType" : "Condition", "id" : "Example-JP-Condition-eCS-ABDPAINInline", "meta" : { "lastUpdated" : "2021-11-26T10:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/eCS/StructureDefinition/JP_Condition_eCS|1.6.0"] }, "language" : "ja", "text" : { "status" : "extensions", "div" : "

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

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

Profile: JP_Condition_eCSversion: null1.6.0)

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 = finished; 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

Language: ja

Profile: JP_Encounter-eCS

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

status: Finished

class: ActCode AMB: 外来

" }, "contained" : [{ "resourceType" : "Encounter", "id" : "Example-Contained-JP-Encounter-AMB", "meta" : { "profile" : ["http://jpfhir.jp/fhir/eCS/StructureDefinition/JP_Encounter_eCS"] }, "language" : "ja", "identifier" : [{ "system" : "http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier", "value" : "192844" }], "status" : "finished", "class" : { "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code" : "AMB", "display" : "外来" } }], "extension" : [{ "url" : "http://jpfhir.jp/fhir/clins/Extension/StructureDefinition/JP_eCS_InstitutionNumber", "valueIdentifier" : { "system" : "http://jpfhir.jp/fhir/core/IdSystem/insurance-medical-institution-no", "value" : "1318814790" } }, { "url" : "http://jpfhir.jp/fhir/eCS/Extension/StructureDefinition/JP_eCS_Department", "valueCodeableConcept" : { "coding" : [{ "system" : "http://jami.jp/SS-MIX2/CodeSystem/ClinicalDepartment", "code" : "08", "display" : "循環器科" }], "text" : "循環器診療科" } }], "identifier" : [{ "system" : "http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier", "value" : "192838" }], "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" }] }], "code" : { "coding" : [{ "system" : "http://medis.or.jp/CodeSystem/master-disease-keyNumber", "code" : "20065011", "display" : "上腹部痛" }], "text" : "上腹部痛" }, "subject" : { "reference" : "urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd" }, "encounter" : { "reference" : "#Example-Contained-JP-Encounter-AMB" }, "note" : [{ "text" : "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。" }] } }, { "fullUrl" : "urn:uuid:5c650562-f4e4-40b3-87c6-e9a0376be7a8", "resource" : { "resourceType" : "Condition", "id" : "Example-JP-Condition-eCS-ANGINAInline", "meta" : { "lastUpdated" : "2021-11-26T10:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/eCS/StructureDefinition/JP_Condition_eCS|1.6.0"] }, "language" : "ja", "text" : { "status" : "generated", "div" : "

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

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

Profile: JP_Condition_eCSversion: null1.6.0)

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\u3000狭心症\u3000２ヶ月治療で軽快。

" }, "identifier" : [{ "system" : "http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier", "value" : "192839-01" }], "clinicalStatus" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical", "code" : "resolved" }] }, "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" }] }], "code" : { "coding" : [{ "system" : "http://medis.or.jp/CodeSystem/master-disease-keyNumber", "code" : "20058911", "display" : "狭心症" }], "text" : "狭心症" }, "subject" : { "reference" : "urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd" }, "onsetDateTime" : "2018", "note" : [{ "text" : "2018年\u3000狭心症\u3000２ヶ月治療で軽快。" }] } }, { "fullUrl" : "urn:uuid:a28198b9-6a23-4677-ba2e-5eb3e17d9792", "resource" : { "resourceType" : "Condition", "id" : "Example-JP-Condition-eCS-FxInline", "meta" : { "lastUpdated" : "2021-11-26T10:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/eCS/StructureDefinition/JP_Condition_eCS|1.6.0"] }, "language" : "ja", "text" : { "status" : "generated", "div" : "

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

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

Profile: JP_Condition_eCSversion: null1.6.0)

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\u3000３ヶ月ギプス固定。

" }, "identifier" : [{ "system" : "http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier", "value" : "192839-02" }], "clinicalStatus" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical", "code" : "resolved" }] }, "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" }] }], "code" : { "extension" : [{ "url" : "http://jpfhir.jp/fhir/core/Extension/StructureDefinition/JP_Condition_DiseasePrefixModifier", "valueCodeableConcept" : { "coding" : [{ "system" : "http://medis.or.jp/CodeSystem/master-disease-modKeyNumber", "code" : "27000358", "display" : "左" }] } }], "coding" : [{ "system" : "http://medis.or.jp/CodeSystem/master-disease-keyNumber", "code" : "20080427", "display" : "前腕骨折" }], "text" : "左前腕骨折" }, "subject" : { "reference" : "urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd" }, "onsetDateTime" : "2021", "note" : [{ "text" : "交通事故で左前腕骨折\u3000３ヶ月ギプス固定。" }] } }, { "fullUrl" : "urn:uuid:711b07ae-d20b-40b0-9aa9-c7f1981409e6", "resource" : { "resourceType" : "AllergyIntolerance", "id" : "Example-JP-AllergyIntolerance-eCS-01Inline", "meta" : { "lastUpdated" : "2023-04-01T10:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/eCS/StructureDefinition/JP_AllergyIntolerance_eCS|1.6.0"], "tag" : [{ "system" : "http://jpfhir.jp/fhir/clins/CodeSystem/JP_ehrshrs_indication", "code" : "LTS", "display" : "長期保存" }] }, "language" : "ja", "text" : { "status" : "additional", "div" : "

アレルギー: さば

" }, "extension" : [{ "url" : "http://jpfhir.jp/fhir/clins/Extension/StructureDefinition/JP_eCS_InstitutionNumber", "valueIdentifier" : { "system" : "http://jpfhir.jp/fhir/core/IdSystem/insurance-medical-institution-no", "value" : "1318814790" } }], "identifier" : [{ "system" : "http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier", "value" : "102934701" }], "clinicalStatus" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical", "code" : "active", "display" : "Active" }] }, "code" : { "coding" : [{ "system" : "http://jpfhir.jp/fhir/core/CodeSystem/JP_JfagyFoodAllergen_CS", "code" : "J9FC11310000", "display" : "さば" }], "text" : "さば" }, "patient" : { "reference" : "urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd" } } }, { "fullUrl" : "urn:uuid:5a1aae74-f720-415a-ba15-a6c8b5d4c5a1", "resource" : { "resourceType" : "AllergyIntolerance", "id" : "Example-JP-AllergyIntolerance-eCS-02Inline", "meta" : { "lastUpdated" : "2023-04-01T10:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/eCS/StructureDefinition/JP_AllergyIntolerance_eCS|1.6.0"], "tag" : [{ "system" : "http://jpfhir.jp/fhir/clins/CodeSystem/JP_ehrshrs_indication", "code" : "LTS", "display" : "長期保存" }] }, "language" : "ja", "text" : { "status" : "additional", "div" : "

アレルギー:キーウイ

発症:2020-04-10 情報源：本人\u3000記録：2024-07-10\u3000記録者：看護師A
" }, "extension" : [{ "url" : "http://jpfhir.jp/fhir/clins/Extension/StructureDefinition/JP_eCS_InstitutionNumber", "valueIdentifier" : { "system" : "http://jpfhir.jp/fhir/core/IdSystem/insurance-medical-institution-no", "value" : "1318814790" } }], "identifier" : [{ "system" : "http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier", "value" : "102934702" }], "clinicalStatus" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical", "code" : "active", "display" : "Active" }] }, "verificationStatus" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/allergyintolerance-verification", "code" : "confirmed", "display" : "Confirmed" }] }, "category" : ["food"], "code" : { "coding" : [{ "system" : "http://jpfhir.jp/fhir/core/CodeSystem/JP_JfagyFoodAllergen_CS", "version" : "20240709", "code" : "J9FA32540000", "display" : "キウイフルーツ" }], "text" : "キーウイ" }, "patient" : { "reference" : "urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd" }, "encounter" : { "reference" : "urn:uuid:7cad1f19-3435-451d-9a71-a81b61f3358e" }, "onsetDateTime" : "2020-04-10", "recordedDate" : "2024-07-10", "recorder" : { "display" : "看護師A" }, "asserter" : { "display" : "本人" }, "note" : [{ "text" : "食べると口の周りが痺れる感じ" }] } }, { "fullUrl" : "urn:uuid:0d51bf2a-4863-b36f-2ad3-cb5ea0df1023", "resource" : { "resourceType" : "AllergyIntolerance", "id" : "Example-JP-AllergyIntolerance-eCS-03Inline", "meta" : { "lastUpdated" : "2023-04-01T10:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/eCS/StructureDefinition/JP_AllergyIntolerance_eCS|1.6.0"], "tag" : [{ "system" : "http://jpfhir.jp/fhir/clins/CodeSystem/JP_ehrshrs_indication", "code" : "LTS", "display" : "長期保存" }] }, "language" : "ja", "text" : { "status" : "additional", "div" : "

ポビドンヨード含嗽後に嘔吐と全身に発疹

" }, "extension" : [{ "url" : "http://jpfhir.jp/fhir/clins/Extension/StructureDefinition/JP_eCS_InstitutionNumber", "valueIdentifier" : { "system" : "http://jpfhir.jp/fhir/core/IdSystem/insurance-medical-institution-no", "value" : "1318814790" } }], "identifier" : [{ "system" : "http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier", "value" : "102934703" }], "clinicalStatus" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical", "code" : "active", "display" : "Active" }] }, "category" : ["medication"], "code" : { "coding" : [{ "system" : "http://jpfhir.jp/fhir/core/CodeSystem/GCM/JP_JfagyMedicationAllergen_CS", "code" : "GCM2260701F1ZZZ", "display" : "【成分名】ポビドンヨード" }], "text" : "ヨードうがい液" }, "patient" : { "reference" : "urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd" }, "encounter" : { "reference" : "urn:uuid:7cad1f19-3435-451d-9a71-a81b61f3358e" }, "note" : [{ "text" : "ポビドンヨード含嗽後に嘔吐と全身に発疹" }], "reaction" : [{ "manifestation" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/iso21090-nullFlavor", "valueCode" : "NI" }] }], "severity" : "severe" }] } }, { "fullUrl" : "urn:uuid:481835ef-0891-45de-a006-087954ab6b7c", "resource" : { "resourceType" : "Observation", "id" : "psExample-JP-Obs-Common-eCS-textOnly01Inline", "meta" : { "lastUpdated" : "2021-11-26T10:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/eCS/StructureDefinition/JP_Observation_Common_eCS"] }, "language" : "ja", "text" : { "status" : "generated", "div" : "

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

" }, "contained" : [{ "resourceType" : "Practitioner", "id" : "Example-Contained-JP-Practitioner-minimun-D002", "meta" : { "profile" : ["http://jpfhir.jp/fhir/core/StructureDefinition/JP_Practitioner"] }, "language" : "ja", "identifier" : [{ "system" : "urn:oid:1.2.392.100495.20.3.41.11311234567", "value" : "D001" }], "name" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/iso21090-EN-representation", "valueCode" : "IDE" }], "text" : "田中 宏" }] }], "identifier" : [{ "system" : "http://jpfhir.jp/fhir/core/IdSystem/resourceInstance-identifier", "value" : "192837" }], "status" : "final", "category" : [{ "coding" : [{ "system" : "http://jpfhir.jp/fhir/core/CodeSystem/JP_SimpleObservationCategory_CS", "code" : "exam", "display" : "Exam" }] }], "code" : { "text" : "腹部所見" }, "subject" : { "reference" : "urn:uuid:0a48a4bf-0d87-4efb-aafd-d45e0842a4dd" }, "effectiveDateTime" : "2021-07-05T11:19:41+09:00", "performer" : [{ "reference" : "#Example-Contained-JP-Practitioner-minimun-D002" }], "valueString" : "上腹部圧痛あり、その他特に所見なし。" } }, { "fullUrl" : "urn:uuid:a6e4fc73-a749-4583-94a7-18e4241b4c75", "resource" : { "resourceType" : "DocumentReference", "id" : "Example-JP-DocRef-eCS-clinical-ccourse-Referral01Inline", "meta" : { "lastUpdated" : "2023-03-31T00:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/eCS/StructureDefinition/JP_DocumentReference_eCS"] }, "language" : "ja", "text" : { "status" : "generated", "div" : "

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
" }, "status" : "current", "type" : { "coding" : [{ "system" : "http://loinc.org", "code" : "11506-3", "display" : "Progress note" }] }, "description" : "臨床経過", "content" : [{ "attachment" : { "contentType" : "application/pdf", "url" : "file:///clinicalCourseExampleData.pdf" } }] } }] }