臺灣牙醫實作指引 (Taiwan Dental Implementation Guide)
0.0.1 - ballot

臺灣牙醫實作指引 (Taiwan Dental Implementation Guide) - Local Development build (v0.0.1) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Example Binary: 牙醫－牙周炎病人自費同意書範例

This content is an example of the 牙周炎病人自費同意書 (TW Periodontal Self-Pay Consent) 之邏輯模型 Logical Model and is not a FHIR Resource

    
{
  "resourceType": "http://dental-ig.fhir.tw/StructureDefinition/TWDentalPeriodontalSelfPayConsent",
  "patientName": {
    "text": "王小明",
    "family": "王",
    "given": [
      "小明"
    ]
  },
  "birthDate": "1980-01-01",
  "medicalRecordNumber": {
    "system": "https://dental-ig.fhir.tw/identifier/medical-record",
    "value": "MR-001"
  },
  "organizationName": "幸福牙醫診所",
  "consentDescription": "本同意書說明牙周炎治療中使用之自費項目，包含材料費用及相關注意事項。",
  "selfPayReasons": [
    {
      "coding": [
        {
          "system": "https://dental-ig.fhir.tw/CodeSystem/selfpay-reason",
          "code": "UPGRADE"
        }
      ],
      "text": "材料升級"
    },
    {
      "coding": [
        {
          "system": "https://dental-ig.fhir.tw/CodeSystem/selfpay-reason",
          "code": "ADVANCED"
        }
      ],
      "text": "進階治療技術"
    }
  ],
  "selfPayOtherReason": "患者要求使用較新材料",
  "selfPayItems": [
    {
      "itemName": "進口生醫材料",
      "unitPrice": {
        "value": 2500,
        "currency": "TWD"
      },
      "quantity": 2,
      "amount": {
        "value": 5000,
        "currency": "TWD"
      }
    },
    {
      "itemName": "特殊手術器械使用費",
      "unitPrice": {
        "value": 1500,
        "currency": "TWD"
      },
      "quantity": 1,
      "amount": {
        "value": 1500,
        "currency": "TWD"
      }
    }
  ],
  "notes": [
    "1. 自費項目費用不包含在健保給付範圍內",
    "2. 治療效果因個人體質而異",
    "3. 如有任何問題請立即聯絡診所"
  ],
  "consentPersonName": {
    "text": "王大明",
    "family": "王",
    "given": [
      "大明"
    ]
  },
  "consentPersonId": "A123456789",
  "consentRelation": "父子",
  "contactPhone": "02-12345678",
  "contactMobile": "0912345678",
  "contactAddress": "台北市信義區信義路五段123號",
  "consentSignature": {
    "type": [
      {
        "system": "urn:iso-astm:E1762-95:2013",
        "code": "1.2.840.10065.1.12.1.1",
        "display": "Author's Signature"
      }
    ],
    "who": {
      "reference": "Patient/Dental-patient-example"
    },
    "when": "2024-01-01T14:00:00+08:00"
  },
  "consentDate": "2024-01-01"
}