臺灣健保署基礎實作指引
0.0.1 - ci-build

臺灣健保署基礎實作指引, published by 衛生福利部中央健康保險署. This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/TWNHIFHIR/base/ and changes regularly. See the Directory of published versions

## Resource Profile: 文件參照-DocumentReference TWNHIBASE

Official URL: https://nhicore.nhi.gov.tw/base/StructureDefinition/DocumentReference-twnhibase | Version: 0.0.1
Draft as of 2025-10-29 | Computable Name: DocumentReferenceTWNHIBASE

此文件參照-DocumentReference TWNHIBASE Profile說明本IG如何進一步定義臺灣核心-文件參照(TW Core DocumentReference) Profile以呈現健保署基礎之治療計畫文件及基因報告

Usages:

- Refer to this Profile: 基因資訊-Observation Diagnostic TWNHIBASE
- Examples for this Profile: DocumentReference/doc-careplan-min, DocumentReference/doc-gene-min, DocumentReference/doc-medicalRecord-min and DocumentReference/doc-test-min

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

- Key Elements Table
- Differential Table
- Snapshot Table
- Statistics/References
- All

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DocumentReference |  | 0..* | TWCoreDocumentReference | 文件的參照
meta | Σ | 1..1 | Meta | 此DocumentReference Resource的metadata
profile | Σ | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: https://nhicore.nhi.gov.tw/base/StructureDefinition/DocumentReference-twnhibase
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
masterIdentifier | S Σ | 0..1 | Identifier | 主版本的識別碼
status | ?!S Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): 文件參照的狀態；應填入所綁定值集中的其中一個代碼。 Required Pattern: current
type | S | 0..1 | CodeableConceptTW | 文件的類型（如果可能，使用 LOINC 代碼） Binding: LOINC Code Document Type值集 (extensible): 應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。
category | S | 1..1 | CodeableConceptTW | 文件的類別 Binding: NHI-健保署-文件類型值集 (required)
coding | S | 1..1 | CodingTW | 由專門術語系統（terminology system）定義的代碼
system | S Σ | 0..1 | uri | 專門術語系統（terminology system）的識別
code | S Σ | 1..1 | code | 系統定義的語法之符號
display | S Σ | 0..1 | string | 由系統定義的表示法
text | S Σ | 0..1 | string | 概念的文字表示法
subject | S Σ | 1..1 | Reference(病人資訊-Patient TWNHIBASE) | 文件描述的對象是誰/是什麼？
date | S Σ | 0..1 | instant | 文件參照的創建時間是何時？
author | S Σ | 0..* | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | Device | TW Core Patient | TW Core RelatedPerson) | 誰以及/或什麼創建了文件
content | S Σ | 1..* | BackboneElement | 被參照的文件
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
attachment | S Σ C | 1..1 | Attachment | 存取文件的位置 Constraints: UploadContent
contentType | S Σ | 1..1 | code | 報告結果-MIMEType Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Required Pattern: application/pdf
url | S Σ | 1..1 | url | 基因報告／治療計畫文件／檢驗(查)附件／病歷資料。（請填寫完整檔案路徑） Example General: http://www.acme.com/logo-small.png Example General: file://PathologyReport01.pdf
title | S Σ | 0..1 | string | 基因報告名稱／治療計畫文件名稱／檢驗(查)附件名稱／病歷資料名稱。 Example General: Official Corporate Logo
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DocumentReference.status | Base | required | DocumentReferenceStatus | 📍4.0.1 | FHIR Std.
DocumentReference.type | Base | extensible | LOINC Code Document Type值集 | 📦2.77 | 臺灣核心實作指引 v0.3
DocumentReference.category | Base | required | NHI-健保署-文件類型值集 | 📦0.0.1 | This IG
DocumentReference.content.​attachment.contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
UploadContent | error | DocumentReference.content.attachment | 填寫格式：file://檔名.副檔名，例如：file://US01.jpg、file://PathologyReport01.pdf、file://GenReport01.pdf、file://王大明病歷.pdf | `url.matches('^file://[a-zA-Z0-9_一-龥()（）－]+.[a-zA-Z]{2,5}$')`
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | DocumentReference | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from TWCoreDocumentReference

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DocumentReference |  | 0..* | TWCoreDocumentReference | 文件的參照
meta |  | 1..1 | Meta | 此DocumentReference Resource的metadata
profile |  | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: https://nhicore.nhi.gov.tw/base/StructureDefinition/DocumentReference-twnhibase
status |  | 1..1 | code | current | superseded | entered-in-error Required Pattern: current
category |  | 1..1 | CodeableConceptTW | 文件的類別 Binding: NHI-健保署-文件類型值集 (required)
coding |  | 1..1 | CodingTW | 由專門術語系統（terminology system）定義的代碼
code |  | 1..1 | code | 系統定義的語法之符號
subject |  | 1..1 | Reference(病人資訊-Patient TWNHIBASE) | 文件描述的對象是誰/是什麼？
content |  |  |  |
attachment | S C | 1..1 | Attachment | 存取文件的位置 Constraints: UploadContent
contentType | S | 1..1 | code | 報告結果-MIMEType Required Pattern: application/pdf
url | S | 1..1 | url | 基因報告／治療計畫文件／檢驗(查)附件／病歷資料。（請填寫完整檔案路徑） Example General: file://PathologyReport01.pdf
title | S | 0..1 | string | 基因報告名稱／治療計畫文件名稱／檢驗(查)附件名稱／病歷資料名稱。
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
DocumentReference.category | Base | required | NHI-健保署-文件類型值集 | 📦0.0.1 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
UploadContent | error | DocumentReference.content.attachment | 填寫格式：file://檔名.副檔名，例如：file://US01.jpg、file://PathologyReport01.pdf、file://GenReport01.pdf、file://王大明病歷.pdf | `url.matches('^file://[a-zA-Z0-9_一-龥()（）－]+.[a-zA-Z]{2,5}$')`

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DocumentReference |  | 0..* | TWCoreDocumentReference | 文件的參照
id | Σ | 0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的DocumentReference紀錄，通常又稱為邏輯性ID。
meta | Σ | 1..1 | Meta | 此DocumentReference Resource的metadata
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
versionId | Σ | 0..1 | id | Version specific identifier
lastUpdated | Σ | 0..1 | instant | When the resource version last changed
source | Σ | 0..1 | uri | Identifies where the resource comes from
profile | Σ | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: https://nhicore.nhi.gov.tw/base/StructureDefinition/DocumentReference-twnhibase
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則
language |  | 0..1 | code | 用以表述DocumentReference Resource內容的語言。 Binding: CommonLanguages (preferred): 人類語言；鼓勵使用CommonLanguages代碼表中的代碼，但不強制一定要使用此代碼表，你也可使用其他代碼表的代碼或單純以文字表示。
Additional Bindings | Purpose
AllLanguages | Max Binding
Example Value: zh-TW
text |  | 0..1 | Narrative | DocumentReference Resource之內容摘要以供人閱讀 This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
masterIdentifier | S Σ | 0..1 | Identifier | 主版本的識別碼
identifier | Σ | 0..* | Identifier | 文件的其他的識別碼
status | ?!S Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): 文件參照的狀態；應填入所綁定值集中的其中一個代碼。 Required Pattern: current
docStatus | Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): 基礎文件的狀態；應填入所綁定值集中的其中一個代碼。
type | S | 0..1 | CodeableConceptTW | 文件的類型（如果可能，使用 LOINC 代碼） Binding: LOINC Code Document Type值集 (extensible): 應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。
category | S | 1..1 | CodeableConceptTW | 文件的類別 Binding: NHI-健保署-文件類型值集 (required)
id |  | 0..1 | string | 唯一可識別ID，以供資料項目間相互參照。
extension |  | 0..* | Extension | 擴充的資料項目 Slice: Unordered, Open by value:url
coding | S | 1..1 | CodingTW | 由專門術語系統（terminology system）定義的代碼
id |  | 0..1 | string | 唯一可識別ID，以供資料項目間相互參照。
extension |  | 0..* | Extension | 擴充的資料項目 Slice: Unordered, Open by value:url
system | S Σ | 0..1 | uri | 專門術語系統（terminology system）的識別
version | Σ | 0..1 | string | 系統的版本—如果相關的話
code | S Σ | 1..1 | code | 系統定義的語法之符號
display | S Σ | 0..1 | string | 由系統定義的表示法
userSelected | Σ | 0..1 | boolean | 此編碼是否由使用者直接選擇？
text | S Σ | 0..1 | string | 概念的文字表示法
subject | S Σ | 1..1 | Reference(病人資訊-Patient TWNHIBASE) | 文件描述的對象是誰/是什麼？
date | S Σ | 0..1 | instant | 文件參照的創建時間是何時？
author | S Σ | 0..* | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | Device | TW Core Patient | TW Core RelatedPerson) | 誰以及/或什麼創建了文件
authenticator |  | 0..1 | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization) | 誰/什麼對文件進行了認證
custodian |  | 0..1 | Reference(TW Core Organization) | 維護此文件的機構
relatesTo | Σ | 0..* | BackboneElement | 與其他文件的關係
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code | Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): 文件之間的關係類型；應填入所綁定值集中的其中一個代碼。
target | Σ | 1..1 | Reference(TW Core DocumentReference) | 存在此關係的目標文件
description | Σ | 0..1 | string | 人可讀的描述。
securityLabel |  | 0..* | CodeableConceptTW | 文件的安全標籤(security-tags) Binding: All Security Labels (extensible): 應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。
content | S Σ | 1..* | BackboneElement | 被參照的文件
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
attachment | S Σ C | 1..1 | Attachment | 存取文件的位置 Constraints: UploadContent
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
contentType | S Σ | 1..1 | code | 報告結果-MIMEType Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Required Pattern: application/pdf
language | Σ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Example General: en-AU
data |  | 0..1 | base64Binary | Data inline, base64ed
url | S Σ | 1..1 | url | 基因報告／治療計畫文件／檢驗(查)附件／病歷資料。（請填寫完整檔案路徑） Example General: http://www.acme.com/logo-small.png Example General: file://PathologyReport01.pdf
size | Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided)
hash | Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed)
title | S Σ | 0..1 | string | 基因報告名稱／治療計畫文件名稱／檢驗(查)附件名稱／病歷資料名稱。 Example General: Official Corporate Logo
creation | Σ | 0..1 | dateTime | Date attachment was first created
format | Σ | 0..1 | Coding | 文件的格式/內容規則。 Binding: DocumentReferenceFormatCodeSet (preferred): 鼓勵使用所綁定值集中的代碼，但不強制一定要使用此值集，你也可使用其他值集的代碼或單純以文字表示。
context | Σ | 0..1 | BackboneElement | 文件的臨床背景
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
encounter |  | 0..* | Reference(TW Core Encounter | EpisodeOfCare) | 文件內容的臨床背景
event |  | 0..* | CodeableConceptTW | 正在記錄的主要臨床行為 Binding: v3 Code System ActCode (example): 可參考所綁定值集，但此值集只是針對這個欄位的一個可能值的範例，不預期也不鼓勵使用者一定要使用此值集的代碼。
period | Σ | 0..1 | Period | 被記錄的服務時間
facilityType |  | 0..1 | CodeableConcept | 病人接受治療的機構類型 Binding: FacilityTypeCodeValueSet (example): 可參考所綁定值集，但此值集只是針對這個欄位的一個可能值的範例，不預期也不鼓勵使用者一定要使用此值集的代碼。
practiceSetting |  | 0..1 | CodeableConceptTW | 內容創建的額外細節(例如：臨床專業) Binding: PracticeSettingCodeValueSet (example): 可參考所綁定值集，但此值集只是針對這個欄位的一個可能值的範例，不預期也不鼓勵使用者一定要使用此值集的代碼。
sourcePatientInfo |  | 0..1 | Reference(TW Core Patient) | 來源的病人人口統計資料
related |  | 0..* | Reference(Resource) | 相關的識別碼或resources
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DocumentReference.meta.​security | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std.
DocumentReference.meta.​tag | Base | example | Common Tags | 📍4.0.1 | FHIR Std.
DocumentReference.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std.
DocumentReference.status | Base | required | DocumentReferenceStatus | 📍4.0.1 | FHIR Std.
DocumentReference.docStatus | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std.
DocumentReference.type | Base | extensible | LOINC Code Document Type值集 | 📦2.77 | 臺灣核心實作指引 v0.3
DocumentReference.category | Base | required | NHI-健保署-文件類型值集 | 📦0.0.1 | This IG
DocumentReference.relatesTo.​code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std.
DocumentReference.securityLabel | Base | extensible | SecurityLabels | 📦4.0.1 | FHIR Std.
DocumentReference.content.​attachment.contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std.
DocumentReference.content.​attachment.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
DocumentReference.content.​format | Base | preferred | DocumentReference Format Code Set | 📦4.0.1 | FHIR Std.
DocumentReference.context.​event | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v6.5
DocumentReference.context.​facilityType | Base | example | Facility Type Code Value Set | 📦4.0.1 | FHIR Std.
DocumentReference.context.​practiceSetting | Base | example | Practice Setting Code Value Set | 📦4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
UploadContent | error | DocumentReference.content.attachment | 填寫格式：file://檔名.副檔名，例如：file://US01.jpg、file://PathologyReport01.pdf、file://GenReport01.pdf、file://王大明病歷.pdf | `url.matches('^file://[a-zA-Z0-9_一-龥()（）－]+.[a-zA-Z]{2,5}$')`
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | DocumentReference | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from TWCoreDocumentReference

Summary

Mandatory: 7 elements
Must-Support: 4 elements

Structures

This structure refers to these other structures:

- 病人資訊-Patient TWNHIBASE (https://nhicore.nhi.gov.tw/base/StructureDefinition/Patient-twnhibase)

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DocumentReference |  | 0..* | TWCoreDocumentReference | 文件的參照
meta | Σ | 1..1 | Meta | 此DocumentReference Resource的metadata
profile | Σ | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: https://nhicore.nhi.gov.tw/base/StructureDefinition/DocumentReference-twnhibase
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
masterIdentifier | S Σ | 0..1 | Identifier | 主版本的識別碼
status | ?!S Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): 文件參照的狀態；應填入所綁定值集中的其中一個代碼。 Required Pattern: current
type | S | 0..1 | CodeableConceptTW | 文件的類型（如果可能，使用 LOINC 代碼） Binding: LOINC Code Document Type值集 (extensible): 應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。
category | S | 1..1 | CodeableConceptTW | 文件的類別 Binding: NHI-健保署-文件類型值集 (required)
coding | S | 1..1 | CodingTW | 由專門術語系統（terminology system）定義的代碼
system | S Σ | 0..1 | uri | 專門術語系統（terminology system）的識別
code | S Σ | 1..1 | code | 系統定義的語法之符號
display | S Σ | 0..1 | string | 由系統定義的表示法
text | S Σ | 0..1 | string | 概念的文字表示法
subject | S Σ | 1..1 | Reference(病人資訊-Patient TWNHIBASE) | 文件描述的對象是誰/是什麼？
date | S Σ | 0..1 | instant | 文件參照的創建時間是何時？
author | S Σ | 0..* | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | Device | TW Core Patient | TW Core RelatedPerson) | 誰以及/或什麼創建了文件
content | S Σ | 1..* | BackboneElement | 被參照的文件
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
attachment | S Σ C | 1..1 | Attachment | 存取文件的位置 Constraints: UploadContent
contentType | S Σ | 1..1 | code | 報告結果-MIMEType Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Required Pattern: application/pdf
url | S Σ | 1..1 | url | 基因報告／治療計畫文件／檢驗(查)附件／病歷資料。（請填寫完整檔案路徑） Example General: http://www.acme.com/logo-small.png Example General: file://PathologyReport01.pdf
title | S Σ | 0..1 | string | 基因報告名稱／治療計畫文件名稱／檢驗(查)附件名稱／病歷資料名稱。 Example General: Official Corporate Logo
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DocumentReference.status | Base | required | DocumentReferenceStatus | 📍4.0.1 | FHIR Std.
DocumentReference.type | Base | extensible | LOINC Code Document Type值集 | 📦2.77 | 臺灣核心實作指引 v0.3
DocumentReference.category | Base | required | NHI-健保署-文件類型值集 | 📦0.0.1 | This IG
DocumentReference.content.​attachment.contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
UploadContent | error | DocumentReference.content.attachment | 填寫格式：file://檔名.副檔名，例如：file://US01.jpg、file://PathologyReport01.pdf、file://GenReport01.pdf、file://王大明病歷.pdf | `url.matches('^file://[a-zA-Z0-9_一-龥()（）－]+.[a-zA-Z]{2,5}$')`
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | DocumentReference | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

Differential View

This structure is derived from TWCoreDocumentReference

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DocumentReference |  | 0..* | TWCoreDocumentReference | 文件的參照
meta |  | 1..1 | Meta | 此DocumentReference Resource的metadata
profile |  | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: https://nhicore.nhi.gov.tw/base/StructureDefinition/DocumentReference-twnhibase
status |  | 1..1 | code | current | superseded | entered-in-error Required Pattern: current
category |  | 1..1 | CodeableConceptTW | 文件的類別 Binding: NHI-健保署-文件類型值集 (required)
coding |  | 1..1 | CodingTW | 由專門術語系統（terminology system）定義的代碼
code |  | 1..1 | code | 系統定義的語法之符號
subject |  | 1..1 | Reference(病人資訊-Patient TWNHIBASE) | 文件描述的對象是誰/是什麼？
content |  |  |  |
attachment | S C | 1..1 | Attachment | 存取文件的位置 Constraints: UploadContent
contentType | S | 1..1 | code | 報告結果-MIMEType Required Pattern: application/pdf
url | S | 1..1 | url | 基因報告／治療計畫文件／檢驗(查)附件／病歷資料。（請填寫完整檔案路徑） Example General: file://PathologyReport01.pdf
title | S | 0..1 | string | 基因報告名稱／治療計畫文件名稱／檢驗(查)附件名稱／病歷資料名稱。
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
DocumentReference.category | Base | required | NHI-健保署-文件類型值集 | 📦0.0.1 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
UploadContent | error | DocumentReference.content.attachment | 填寫格式：file://檔名.副檔名，例如：file://US01.jpg、file://PathologyReport01.pdf、file://GenReport01.pdf、file://王大明病歷.pdf | `url.matches('^file://[a-zA-Z0-9_一-龥()（）－]+.[a-zA-Z]{2,5}$')`

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DocumentReference |  | 0..* | TWCoreDocumentReference | 文件的參照
id | Σ | 0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的DocumentReference紀錄，通常又稱為邏輯性ID。
meta | Σ | 1..1 | Meta | 此DocumentReference Resource的metadata
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
versionId | Σ | 0..1 | id | Version specific identifier
lastUpdated | Σ | 0..1 | instant | When the resource version last changed
source | Σ | 0..1 | uri | Identifies where the resource comes from
profile | Σ | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: https://nhicore.nhi.gov.tw/base/StructureDefinition/DocumentReference-twnhibase
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則
language |  | 0..1 | code | 用以表述DocumentReference Resource內容的語言。 Binding: CommonLanguages (preferred): 人類語言；鼓勵使用CommonLanguages代碼表中的代碼，但不強制一定要使用此代碼表，你也可使用其他代碼表的代碼或單純以文字表示。
Additional Bindings | Purpose
AllLanguages | Max Binding
Example Value: zh-TW
text |  | 0..1 | Narrative | DocumentReference Resource之內容摘要以供人閱讀 This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
masterIdentifier | S Σ | 0..1 | Identifier | 主版本的識別碼
identifier | Σ | 0..* | Identifier | 文件的其他的識別碼
status | ?!S Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): 文件參照的狀態；應填入所綁定值集中的其中一個代碼。 Required Pattern: current
docStatus | Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): 基礎文件的狀態；應填入所綁定值集中的其中一個代碼。
type | S | 0..1 | CodeableConceptTW | 文件的類型（如果可能，使用 LOINC 代碼） Binding: LOINC Code Document Type值集 (extensible): 應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。
category | S | 1..1 | CodeableConceptTW | 文件的類別 Binding: NHI-健保署-文件類型值集 (required)
id |  | 0..1 | string | 唯一可識別ID，以供資料項目間相互參照。
extension |  | 0..* | Extension | 擴充的資料項目 Slice: Unordered, Open by value:url
coding | S | 1..1 | CodingTW | 由專門術語系統（terminology system）定義的代碼
id |  | 0..1 | string | 唯一可識別ID，以供資料項目間相互參照。
extension |  | 0..* | Extension | 擴充的資料項目 Slice: Unordered, Open by value:url
system | S Σ | 0..1 | uri | 專門術語系統（terminology system）的識別
version | Σ | 0..1 | string | 系統的版本—如果相關的話
code | S Σ | 1..1 | code | 系統定義的語法之符號
display | S Σ | 0..1 | string | 由系統定義的表示法
userSelected | Σ | 0..1 | boolean | 此編碼是否由使用者直接選擇？
text | S Σ | 0..1 | string | 概念的文字表示法
subject | S Σ | 1..1 | Reference(病人資訊-Patient TWNHIBASE) | 文件描述的對象是誰/是什麼？
date | S Σ | 0..1 | instant | 文件參照的創建時間是何時？
author | S Σ | 0..* | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | Device | TW Core Patient | TW Core RelatedPerson) | 誰以及/或什麼創建了文件
authenticator |  | 0..1 | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization) | 誰/什麼對文件進行了認證
custodian |  | 0..1 | Reference(TW Core Organization) | 維護此文件的機構
relatesTo | Σ | 0..* | BackboneElement | 與其他文件的關係
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code | Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): 文件之間的關係類型；應填入所綁定值集中的其中一個代碼。
target | Σ | 1..1 | Reference(TW Core DocumentReference) | 存在此關係的目標文件
description | Σ | 0..1 | string | 人可讀的描述。
securityLabel |  | 0..* | CodeableConceptTW | 文件的安全標籤(security-tags) Binding: All Security Labels (extensible): 應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。
content | S Σ | 1..* | BackboneElement | 被參照的文件
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
attachment | S Σ C | 1..1 | Attachment | 存取文件的位置 Constraints: UploadContent
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
contentType | S Σ | 1..1 | code | 報告結果-MIMEType Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Required Pattern: application/pdf
language | Σ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Example General: en-AU
data |  | 0..1 | base64Binary | Data inline, base64ed
url | S Σ | 1..1 | url | 基因報告／治療計畫文件／檢驗(查)附件／病歷資料。（請填寫完整檔案路徑） Example General: http://www.acme.com/logo-small.png Example General: file://PathologyReport01.pdf
size | Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided)
hash | Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed)
title | S Σ | 0..1 | string | 基因報告名稱／治療計畫文件名稱／檢驗(查)附件名稱／病歷資料名稱。 Example General: Official Corporate Logo
creation | Σ | 0..1 | dateTime | Date attachment was first created
format | Σ | 0..1 | Coding | 文件的格式/內容規則。 Binding: DocumentReferenceFormatCodeSet (preferred): 鼓勵使用所綁定值集中的代碼，但不強制一定要使用此值集，你也可使用其他值集的代碼或單純以文字表示。
context | Σ | 0..1 | BackboneElement | 文件的臨床背景
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
encounter |  | 0..* | Reference(TW Core Encounter | EpisodeOfCare) | 文件內容的臨床背景
event |  | 0..* | CodeableConceptTW | 正在記錄的主要臨床行為 Binding: v3 Code System ActCode (example): 可參考所綁定值集，但此值集只是針對這個欄位的一個可能值的範例，不預期也不鼓勵使用者一定要使用此值集的代碼。
period | Σ | 0..1 | Period | 被記錄的服務時間
facilityType |  | 0..1 | CodeableConcept | 病人接受治療的機構類型 Binding: FacilityTypeCodeValueSet (example): 可參考所綁定值集，但此值集只是針對這個欄位的一個可能值的範例，不預期也不鼓勵使用者一定要使用此值集的代碼。
practiceSetting |  | 0..1 | CodeableConceptTW | 內容創建的額外細節(例如：臨床專業) Binding: PracticeSettingCodeValueSet (example): 可參考所綁定值集，但此值集只是針對這個欄位的一個可能值的範例，不預期也不鼓勵使用者一定要使用此值集的代碼。
sourcePatientInfo |  | 0..1 | Reference(TW Core Patient) | 來源的病人人口統計資料
related |  | 0..* | Reference(Resource) | 相關的識別碼或resources
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DocumentReference.meta.​security | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std.
DocumentReference.meta.​tag | Base | example | Common Tags | 📍4.0.1 | FHIR Std.
DocumentReference.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std.
DocumentReference.status | Base | required | DocumentReferenceStatus | 📍4.0.1 | FHIR Std.
DocumentReference.docStatus | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std.
DocumentReference.type | Base | extensible | LOINC Code Document Type值集 | 📦2.77 | 臺灣核心實作指引 v0.3
DocumentReference.category | Base | required | NHI-健保署-文件類型值集 | 📦0.0.1 | This IG
DocumentReference.relatesTo.​code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std.
DocumentReference.securityLabel | Base | extensible | SecurityLabels | 📦4.0.1 | FHIR Std.
DocumentReference.content.​attachment.contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std.
DocumentReference.content.​attachment.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
DocumentReference.content.​format | Base | preferred | DocumentReference Format Code Set | 📦4.0.1 | FHIR Std.
DocumentReference.context.​event | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v6.5
DocumentReference.context.​facilityType | Base | example | Facility Type Code Value Set | 📦4.0.1 | FHIR Std.
DocumentReference.context.​practiceSetting | Base | example | Practice Setting Code Value Set | 📦4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
UploadContent | error | DocumentReference.content.attachment | 填寫格式：file://檔名.副檔名，例如：file://US01.jpg、file://PathologyReport01.pdf、file://GenReport01.pdf、file://王大明病歷.pdf | `url.matches('^file://[a-zA-Z0-9_一-龥()（）－]+.[a-zA-Z]{2,5}$')`
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | DocumentReference | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from TWCoreDocumentReference

Summary

Mandatory: 7 elements
Must-Support: 4 elements

Structures

This structure refers to these other structures:

- 病人資訊-Patient TWNHIBASE (https://nhicore.nhi.gov.tw/base/StructureDefinition/Patient-twnhibase)

Other representations of profile: CSV, Excel, Schematron