{ "resourceType" : "Bundle", "id" : "Bundle-CLINS-Referral-NoEntry-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" : "compositionReferralExample01InlineNoEntry", "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 compositionReferralExample01InlineNoEntry

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

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" }, "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Practitioner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" : "
東京都港区新橋１−２−３
電話:03-9876-5432>
港診療所
眼科
大河内 勘三郎
" }, "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" : "
紹介先医療機関名：東京第一テスト病院
内科
紹介先医師：野口 英世丸先生
" }, "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。
" } }, { "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" : "
2022-06-09 上腹部痛、2022-05 腰痛
" } }, { "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。
" } }, { "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。
" } }, { "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、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）、ヨード禁（ポビドンヨード含嗽後に嘔吐と全身に発疹）
" } }, { "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。
" } }, { "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" : "
⾷欲不振と⼼窩部痛を認めた．悪⼼嘔吐がみられ，吐物に新鮮⾎が混⼊していたため救急外来を受診し，緊急⼊院となった．
⼊院時現症:⾝⻑162.5cm，体重45.2kg，⾎圧80/60mmHg，脈拍80/分，整，体温36.4．眼瞼結膜に貧⾎を認めた．
腹部は平坦，軟で腫瘤や圧痛なし．腸蠕動⾳正常．
⼊院時検査成績(Table1):末梢⾎液検査で，Hb5.0g/dl，Ht15.5%と著明な貧⾎を認めた．
上部消化管内視鏡検査:⼊院翌⽇の検査では，残胃吻合部後壁に約2.5cmの潰瘍形成を認め，潰瘍底に凝⾎塊の付着した露出⾎管と思われる隆起がみられたが，新鮮出⾎はなく，抗潰瘍薬投与による経過観察となった．
" } }, { "title" : "投薬指示", "code" : { "coding" : [{ "system" : "http://jpfhir.jp/fhir/clins/CodeSystem/document-section", "code" : "430", "display" : "投薬指示セクション" }] }, "text" : { "status" : "additional", "div" : "
タケキャブ錠10mg1錠\u3000１日2回\u3000朝食後、就寝時
レバミピド錠100mg1錠\u3000\u3000１日3回毎食後
" } }] }, { "title" : "備考・連絡情報", "code" : { "coding" : [{ "system" : "http://jpfhir.jp/fhir/clins/CodeSystem/document-section", "code" : "220", "display" : "備考・連絡情報セクション" }] }, "text" : { "status" : "additional", "div" : "
よろしくお願いします。
" } }] } }, { "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:3e6a0ba2-d781-4fd7-9de6-e077b690daed", "resource" : { "resourceType" : "Practitioner", "id" : "Example-JP-Practitioner-eCS-ReferralFrom02Inline", "meta" : { "lastUpdated" : "2021-11-26T10:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/eCS/StructureDefinition/JP_Practitioner_eCS|1.6.0"] }, "language" : "ja", "text" : { "status" : "generated", "div" : "

Generated Narrative: Practitioner Example-JP-Practitioner-eCS-ReferralFrom02Inline

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

Profile: JP_Practitioner_eCSversion: null1.6.0)

name: 大河内 勘三郎(Official)

" }, "name" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/iso21090-EN-representation", "valueCode" : "IDE" }], "use" : "official", "text" : "大河内 勘三郎" }] } }, { "fullUrl" : "urn:uuid:f11535c2-043d-43b6-bf99-b8298ea3c946", "resource" : { "resourceType" : "Practitioner", "id" : "Example-JP-Practitioner-eCS-ReferralTo02Inline", "meta" : { "lastUpdated" : "2021-11-26T10:00:00+09:00", "profile" : ["http://jpfhir.jp/fhir/eCS/StructureDefinition/JP_Practitioner_eCS|1.6.0"] }, "language" : "ja", "text" : { "status" : "generated", "div" : "

Generated Narrative: Practitioner Example-JP-Practitioner-eCS-ReferralTo02Inline

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

Profile: JP_Practitioner_eCSversion: null1.6.0)

name: 野口 英世丸(Official)

" }, "name" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/iso21090-EN-representation", "valueCode" : "IDE" }], "use" : "official", "text" : "野口 英世丸" }] } }, { "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" }] } }] }