# entry[].resource.text.div
Generated Narrative with Details

id: 180f219f-97a8-486d-99d9-ed631fe4fc57

meta:

status: final

type: Discharge Summary from Responsible Clinician (Details : {LOINC code '28655-9' = 'Physician attending Discharge summary)

encounter: http://fhir.healthintersections.com.au/open/Encounter/doc-example

date: 01/02/2013 12:30:02 PM

author: Doctor Dave

title: Discharge Summary

confidentiality: N

# entry[].resource.type.text
Discharge Summary from Responsible Clinician

# entry[].resource.section[].text.div
Details |
Acute Asthmatic attack. Was wheezing for days prior to admission. |

# entry[].resource.section[].text.div
Medication | Last Change | Last ChangeReason
Theophylline 200mg BD after meals | continued
Ventolin Inhaler | stopped | Getting side effect of tremor

# entry[].resource.section[].code.coding[].display
Allergies and adverse reactions Document

# entry[].resource.section[].text.div
Allergen | Reaction
Doxycycline | Hives

# entry[].resource.text.div
門診病歷

身分證字號 | 病歷號 | 病人姓名 | 性別 | 出生日期 | 文件列印日期 | 醫師姓名 | 醫師記錄日期時間 | 醫院名稱 | 科別 | 門診日期
K100704781 | 0001557021 | 陳鐵雄 | M | 19420308 | 20210112125936 | 魏日華 | 20210112103256 | 敏盛綜合醫院 | 心臟血管內 | 20210112

# entry[].resource.section[].text.div
病人血型及D抗原性血型 : 未知 D抗原性 : 未知

# entry[].resource.section[].text.div
N/A

# entry[].resource.section[].text.div
NKA

# entry[].resource.section[].text.div
就診年齡、職業及就醫身分別就診年齡 : 78歲10月職業 : N/A 就醫身分別 : 健保

# entry[].resource.section[].text.div
E08.40 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified N40.1 Enlarged prostate with lower urinary tract symptoms I10 Essential (primary) hypertension E78.5 Hyperlipidemia, unspecified K73.9 Chronic hepatitis, unspecified

# entry[].resource.section[].entry[].display
Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified

# entry[].resource.section[].entry[].display
Enlarged prostate with lower urinary tract symptoms

# entry[].resource.section[].text.div
主觀描述、客觀描述及評估主觀描述 : H/T ,DM ,HBV carrier f/u at our clinic ,R,T RENAL OP RECISION ,ONLY L,T RENAL 100-10-20 ,only diamicron 1 # Qd use , cough with itching sensation ,R,T KIDNEY /P NEPHRECTOMY,L,T RENAL CYST at 29 y/o, bw; 72,108-1-10 FINARIDE &GLUCOPHAGE STILL HAVE,POOR SLEEP 107-5-3 , proscar use at uro ,ask refill,cough severe , rhinorrhea ,108-1-10,SUGGEST HOLD SOUP,108-7-18,NEED URICEF,109-6-11, r,t knee pain ,hold xanax till next time,109-9-3,BPH WITH FINARIDE TX visit here for heart rates all >100 BW loss for kgs due to sug from 70kgs to 63kgs 客觀描述 : 108-12-18,tg:171,ldl:73,gpt:34,chol:149,hba1c:7.2,glu:139,uricef 1#bid use at last doctor,keep hold lipid drug ,109-3-19,bp:145/78,hr:86,109-3-10,glu:132,hba1c:7.1,tg:94 ,hdl: 34,cr:0.98,gpt:0.98,gpt:37,chol:189,got: 28,ld:136.egfr:78.6,give chronic luipid control,uacr:51.1 ,afp: 1.075 ,hbeag(-),109-6-4,uacr:54.3,cr: 1.08 ,hdl:37,tg:88,cr:1.08 ,gpt: 52 ,got:35,ldl:71,egfr:70.2,glu:137,hba1c:6.8,109-6-4,abd echo: liver cyst s/p r,t side nephrectomy , l,t 1.8cm cyst,109-8-27,GLU:124,HBA1C:7.1,TG: 61,HDL:38,CR:1.05,GPT:54,CHOL: 115,GOT:34,LDL:65,EGFr:72.6,109-9-3,CHOL:133,HDL:62,LDL:94,109-11-12,UACR:36.2,HBA1C:7.1,GLU:140,TG: 63,HDL:36,CR:1.02,GPT:46,CHOL:111,GOT:31,LDL:64,EGFR:75,109-11-26,BP:120/72,HR:72, 評估 : N/A

# entry[].resource.section[].text.div
項次 處置代碼 處置名稱 數量 單位 部位 註記 1 09106C 游離甲狀腺素免疫分析 Free T4(EIA/LIA) +0001.00 None 11Blood None 2 09112C 甲狀腺刺激素免疫分析 TSH(EIA/LIA)(檢驗科) +0001.00 None 11Blood None 3 07009C 糞便常規檢查(包括外觀、蟲 +0001.00 None 31Stool None 4 12007C α－胎兒蛋白檢驗 AFP α-fetoprotein（EIA/LIA）(檢驗科) +0001.00 None 11Blood None 5 12021C 癌胚胎抗原檢驗 CEA(檢驗科) +0001.00 None 11Blood None 6 12079C CA-199腫瘤標記 (EIA/LIA法) +0001.00 None 11Blood None 7 18001C E.K.G.(在檢驗科執行) +0001.00 None None None 8 32001C Chest PA view +0001.00 None None None 9 18005C 大人超音波心臟圖包括單面雙面(心臟中心) +0001.00 None None BW loss

# entry[].resource.section[].text.div
項次 處方箋種類註記 藥品代碼 藥品商品名稱 藥品學名 劑型 劑量 劑量單位 頻率 給藥途徑 給藥日數 給藥總量 給藥總量單位 實際給藥總量 實際給藥總量單位 磨粉註記 註記 特殊劑量頻率 1 GENRL AB230371G0 Cardolol(心康樂) 10mg/tab 錠 Propranolol HCl 10mg/tab M 1 TAB 每天三次；三餐飯後(TID) 口服(PO) 007 +0021.00 TAB +0021.00 TAB N None None

# entry[].resource.text.div
Generated Narrative with Details

id: example-mixed

status: final

type: Neonatal perinatal medicine Discharge summary (Details : {LOINC code '78418-1' = 'Neonatal perinatal medicine Discharge summary', given as 'Neonatal perinatal medicine Discharge summary'})

category: Report (Details : {LOINC code 'LP173421-1' = 'Report', given as 'Report'})

date: 30/10/2018 4:56:04 PM

author: Harold Hippocrates, MD

title: Discharge Summary (Neonatal Service)

confidentiality: N

Attesters

- | Mode | Time | Party
* | legal | 04/01/2012 9:10:14 AM | Harold Hippocrates, MD

custodian: Good Health Clinic

# entry[].resource.type.coding[].display
Neonatal perinatal medicine Discharge summary

# entry[].resource.section[].text.div
(snip)

# entry[].resource.section[].text.div
(snip)

# entry[].resource.text.div
Consultation note for Henry Levin the 7th

Managed by Good Health Clinic

# entry[].resource.section[].text.div
Code | Date | Type | BodySite | Severity
Stroke | 2010-07-18 | Diagnosis | |
Burnt Ear | 2012-05-24 | Diagnosis | Left Ear |
Asthma | 2012-11-12 | Finding | | Mild

# entry[].resource.section[].code.coding[].display
History of family member diseases Narrative

# entry[].resource.section[].text.div
History of family member diseases - not available