臺灣核心實作指引(TW Core IG), published by 衛生福利部. This guide is not an authorized publication; it is the continuous build for version 0.3.2 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cctwFHIRterm/MOHW_TWCoreIG_Build/ and changes regularly. See the Directory of published versions
Official URL: https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Condition-twcore | Version: 0.3.2 | |||
Active as of 2024-12-20 | Computable Name: TWCoreCondition |
此臺灣核心-病情、問題或診斷(TW Core Condition) Profile說明本IG如何進一步定義FHIR的Condition Resource以呈現有關病情、問題或診斷的詳細資料。
就是指某個健康問題或病情已經到了需要特別注意或處理的地步。
Condition 是FHIR中用於記錄和關注特定臨床狀況、問題、診斷或其他相關事件的一種 resource。它在FHIR的工作流程中被劃分為一種event resource,用來捕捉那些需要特別關注的健康狀況。例如:Condition可以用來記錄在一次診療過程中的診斷,或者記錄在醫生的問題清單(Problem List)上的某個項目,甚至是一些還沒有列入問題清單的關注點。
Condition不僅限於醫生基於臨床推理所做出的診斷,也包括那些醫生認為可能對病人有害或需要進一步調查、持續監測和管理的健康問題。例如:如果一個病人被診斷出有心臟疾病的風險,這將被記錄為一個Condition,因為它需要醫生和病人的持續關注和管理。
Condition resource 也可以用來記錄病人某種通常不會帶來負面結果的健康狀態,例如:懷孕。它也可以用來記錄手術後的狀況,比如截肢手術後的截肢狀況。
雖然 Condition 經常是基於醫生對病人健康狀況某一方面的評估和斷言,但病人、相關人士或任何照護團隊成員也可能表達 Condition。醫生可能會對病人的某個狀況(例如:厭食)感到擔憂,而病人本人可能對此不關心。同樣地,病人可能有一個狀況(例如:脫髮),但這個狀況可能不足夠重要,以至於不需要被列入醫生的問題清單上。
例如以下每一種 Condition 都可能因為直接或間接影響病人健康而變得重要,以至於應該被列入問題或關注清單上。例如:「易跌倒」的Condition可能會讓醫生增加對病人的跌倒預防措施,而「家族心血管疾病史」的Condition則提示醫生和病人需要對心血管健康給予更多的關注。這些Condition的記錄有助於提供一個全面的病人健康概況,並指導臨床決策和病人照護計劃。
這些例子也可以使用其他 resources 來表示,例如:家庭成員病史(FamilyMemberHistory)、檢驗檢查(Observation)或處置(Procedure)。
Condition resource 在 FHIR 中是一個關鍵工具,用於記錄那些達到需要關注程度的健康狀況,如疾病、診斷或其他臨床問題。例如:當一位病人被診斷出有糖尿病時,這個狀態就會被記錄為一個 Condition,這不僅對醫生有重要意義,也關係到病人的未來治療計劃。這個 resource 通常被其他 FHIR resources 參照作為某些行動的「原因」。舉個例子,如果一個病人需要特定的藥物來控制他們的高血壓,藥品請求(MedicationRequest) resource就可能參照一個 Condition resource 來解釋為什麼需要這種藥品。同樣地,一項處置或手術(Procedure)或服務請求(ServiceRequest)也可能參照 Condition 來說明進行手術或提供服務的原因。
然而,Condition resource 並不是用來記錄導致 Condition 記錄的初步跡象和症狀(不論主觀或客觀資訊)。這些資訊通常是用檢驗檢查(Observation)resources 來紀錄。例如一位病人初次出現頭痛時,這可能會作為一個 Observation 被記錄,但如果頭痛持續且成為了關注的重點,進而可能與腦膜炎相關,那麼它就可能作為一個 Condition 被記錄下來。
當一個症狀解決了且不需要長期管理時,或當一個症狀有助於確立一個 Condition 時,應該使用 Observation resource。反之,當一個症狀需要長期管理或跟踪,或在醫生尚未確定具體診斷時用作問題的代表時,就應該使用 Condition resource。
特別是在涉及到過敏或不耐症時,Condition 和 AllergyIntolerance resources 都可能被使用。但是,為了讓這些資訊對決策支持有實際幫助,僅使用 Condition resource 是不夠的,因為過敏或不耐症需要以 AllergyIntolerance 的形式來具體表示。
Condition resource 被廣泛參照於多種 FHIR resources 中,如醫療不良事件(AdverseEvent)、預約(Appointment)、照護計畫(CarePlan)、照護團隊(CareTeam)理賠申請(Claim)、臨床臆斷(ClinicalImpression)、通訊(Communication)、 通訊請求(CommunicationRequest)、合約(Contract)、承保範圍資格請求(CoverageEligibilityRequest)、設備請求(DeviceRequest)、設備使用聲明(DeviceUseStatement)、就醫事件(Encounter)、照護事件(EpisodeOfCare)、利益說明(ExplanationOfBenefit)、家族成員病史(FamilyMemberHistory)、目標(Goal)、指導回應(GuidanceResponse)、 影像檢查(ImagingStudy)、疫苗接種(Immunization)、給藥(MedicationAdministration)、藥品請求(MedicationRequest、用藥聲明(MedicationStatement)、處置或手術(Procedure)、一組請求(RequestGroup)、風險評估(RiskAssessment)、服務請求(ServiceRequest)及供應品請求(SupplyRequest),顯示了它在整個醫療和照護過程中,從診斷到治療計劃制定,再到長期健康管理的關鍵作用。
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Condition
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | 0..* | Condition | 有關病情、問題或診斷的詳細資訊 | |||||
id | 0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的Condition紀錄,通常又稱為邏輯性ID。 | |||||
meta | 0..1 | Meta | 此Condition Resource的metadata | |||||
implicitRules | 0..1 | uri | 創建此內容所依據的一組規則 | |||||
language | 0..1 | code | 用以表述Condition 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。
Example Value: zh-TW | |||||
text | 0..1 | Narrative | Condition Resource之內容摘要以供人閱讀 | |||||
identifier | 0..* | Identifier | 此病情、問題或診斷的外部識別碼 | |||||
clinicalStatus | S | 1..1 | CodeableConceptTW | active | recurrence | relapse | inactive | remission | resolved ,病情、問題或診斷的臨床狀態。 Binding: ConditionClinicalStatusCodes (required): 應填入所綁定值集中的其中一個代碼。 | ||||
verificationStatus | S | 0..1 | CodeableConceptTW | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error ,支持或拒絕病情、問題或診斷的臨床狀態的驗證狀態。 Binding: ConditionVerificationStatus (required): 應填入所綁定值集中的其中一個代碼。 | ||||
category | S | 1..1 | CodeableConceptTW | problem-list-item | encounter-diagnosis ,指定病情、問題或診斷的類別。 Binding: ConditionCategoryCodes (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。 | ||||
severity | S | 0..1 | CodeableConceptTW | 病情、問題或診斷的主觀嚴重程度 Binding: Condition/DiagnosisSeverity (extensible): 臨床醫生對病情、問題或診斷嚴重程度的主觀評價;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。 | ||||
code | S | 0..1 | CodeableConceptTW | 病情、問題或診斷的識別 Binding: Condition/Problem/DiagnosisCodes (example): 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 | ||||
Slices for coding | 0..* | CodingTW | 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 Slice: Unordered, Open by pattern:$this | |||||
coding:icd10-cm-2023 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (required) | ||||
coding:icd10-cm-2021 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2021年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:icd10-cm-2014 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:icd9-cm-2001 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required) | ||||
coding:absentOrUnknownProblem | S | 0..1 | CodingTW | 不存在的問題或未知問題的代碼 Binding: Absent or Unknown Problems - IPS (required): 應填入所綁定值集中的其中一個代碼。 | ||||
coding:sct | S | 0..1 | CodingTW | 此為SNOMED CT診斷代碼,若機構已有購買相關授權,亦可使用。 Binding: SNOMED CT診斷代碼值集 (required): 應填入所綁定值集中的其中一個代碼。 | ||||
bodySite | S | 0..* | CodeableConceptTW | 如果相關請填寫解剖位置 Binding: SNOMEDCTBodyStructures (extensible): 描述解剖位置的代碼。可包括側面;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。 | ||||
subject | S | 1..1 | Reference(TW Core Patient | Group) | 誰有此病情、問題或診斷? | ||||
encounter | 0..1 | Reference(TW Core Encounter) | 作為病情、問題或診斷紀錄的一部分的就醫(Encounter)紀錄 | |||||
onset[x] | S | 0..1 | 估計的或實際的日期、日期—時間或年齡。 | |||||
onsetDateTime | dateTime S | |||||||
onsetAge | Age | |||||||
onsetPeriod | Period | |||||||
onsetRange | Range | |||||||
onsetString | string | |||||||
abatement[x] | S | 0..1 | 何時解決/緩解 | |||||
abatementDateTime | dateTime S | |||||||
abatementAge | Age | |||||||
abatementPeriod | Period | |||||||
abatementRange | Range | |||||||
abatementString | string | |||||||
recordedDate | 0..1 | dateTime | 記錄的日期 | |||||
recorder | 0..1 | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | TW Core RelatedPerson) | 誰記錄此病情、問題或診斷 | |||||
asserter | S | 0..1 | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | TW Core RelatedPerson) | 聲稱有此病情、問題或診斷的人 | ||||
stage | 0..* | BackboneElement | 分期(stage)/分級(grade),通常是正式的評估。 | |||||
summary | 0..1 | CodeableConceptTW | 簡單的摘要(特定疾病)。 Binding: ConditionStage (extensible): 描述病情、問題或診斷分期的代碼(例如:癌症分期)。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。 | |||||
assessment | 0..* | Reference(ClinicalImpression | TW Core DiagnosticReport | TW Core Observation Laboratory Result | TW Core Observation Vital Signs) | 正式的評估記錄 | |||||
type | 0..1 | CodeableConceptTW | 分期的種類 Binding: ConditionStageType (extensible): 病情、問題或診斷分期種類的代碼(如臨床或病理);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。 | |||||
evidence | 0..* | BackboneElement | 支持的證據 | |||||
code | 0..* | CodeableConceptTW | 表現/症狀 Binding: ManifestationAndSymptomCodes (extensible): 病情、問題或診斷的表現或症狀之代碼;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。 | |||||
detail | 0..* | Reference(Resource) | 在其他地方找到的支持資訊 | |||||
note | S | 0..* | Annotation | 關於此Condition的附加資訊 | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Condition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard
| ||||
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | ||||
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | ||||
Condition.category | extensible | ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard | ||||
Condition.severity | extensible | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | ||||
Condition.code | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Condition.code.coding:icd10-cm-2023 | required | TW2023ICD10CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2023-tw from this IG | ||||
Condition.code.coding:icd10-cm-2021 | required | TW2021ICD10CM (a valid code from 臺灣健保署2021年中文版ICD-10-CM)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2021-tw from this IG | ||||
Condition.code.coding:icd10-cm-2014 | required | TW2014ICD10CM (a valid code from 臺灣健保署2014年中文版ICD-10-CM)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2014-tw from this IG | ||||
Condition.code.coding:icd9-cm-2001 | required | TW2001ICD9CM (a valid code from 臺灣健保署2001年中文版ICD-9-CM)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw from this IG | ||||
Condition.code.coding:absentOrUnknownProblem | required | AbsentOrUnknownProblemsUvIpshttp://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips | ||||
Condition.code.coding:sct | required | TWConditionCodeSCThttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw from this IG | ||||
Condition.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Condition.stage.summary | extensible | ConditionStagehttp://hl7.org/fhir/ValueSet/condition-stage from the FHIR Standard | ||||
Condition.stage.type | extensible | ConditionStageTypehttp://hl7.org/fhir/ValueSet/condition-stage-type from the FHIR Standard | ||||
Condition.evidence.code | extensible | ManifestationAndSymptomCodeshttp://hl7.org/fhir/ValueSet/manifestation-or-symptom from the FHIR Standard |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | Condition | 有關病情、問題或診斷的詳細資訊 con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management | ||||
id | Σ | 0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的Condition紀錄,通常又稱為邏輯性ID。 | ||||
meta | Σ | 0..1 | Meta | 此Condition Resource的metadata ele-1: All FHIR elements must have a @value or children | ||||
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 ele-1: All FHIR elements must have a @value or children | ||||
language | 0..1 | code | 用以表述Condition 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。
ele-1: All FHIR elements must have a @value or children Example Value: zh-TW | |||||
text | 0..1 | Narrative | Condition Resource之內容摘要以供人閱讀 ele-1: All FHIR elements must have a @value or children | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
identifier | Σ | 0..* | Identifier | 此病情、問題或診斷的外部識別碼 ele-1: All FHIR elements must have a @value or children | ||||
clinicalStatus | S | 1..1 | CodeableConceptTW | active | recurrence | relapse | inactive | remission | resolved ,病情、問題或診斷的臨床狀態。 Binding: ConditionClinicalStatusCodes (required): 應填入所綁定值集中的其中一個代碼。 ele-1: All FHIR elements must have a @value or children | ||||
verificationStatus | S | 0..1 | CodeableConceptTW | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error ,支持或拒絕病情、問題或診斷的臨床狀態的驗證狀態。 Binding: ConditionVerificationStatus (required): 應填入所綁定值集中的其中一個代碼。 ele-1: All FHIR elements must have a @value or children | ||||
category | S | 1..1 | CodeableConceptTW | problem-list-item | encounter-diagnosis ,指定病情、問題或診斷的類別。 Binding: ConditionCategoryCodes (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。 ele-1: All FHIR elements must have a @value or children | ||||
severity | S | 0..1 | CodeableConceptTW | 病情、問題或診斷的主觀嚴重程度 Binding: Condition/DiagnosisSeverity (extensible): 臨床醫生對病情、問題或診斷嚴重程度的主觀評價;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。 ele-1: All FHIR elements must have a @value or children | ||||
code | S | 0..1 | CodeableConceptTW | 病情、問題或診斷的識別 Binding: Condition/Problem/DiagnosisCodes (example): 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 ele-1: All FHIR elements must have a @value or children | ||||
Slices for coding | S | 0..* | CodingTW | 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 Slice: Unordered, Open by pattern:$this ele-1: All FHIR elements must have a @value or children | ||||
coding:icd10-cm-2023 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (required) ele-1: All FHIR elements must have a @value or children | ||||
coding:icd10-cm-2021 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2021年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。 ele-1: All FHIR elements must have a @value or children | ||||
coding:icd10-cm-2014 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。 ele-1: All FHIR elements must have a @value or children | ||||
coding:icd9-cm-2001 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required) ele-1: All FHIR elements must have a @value or children | ||||
coding:absentOrUnknownProblem | S | 0..1 | CodingTW | 不存在的問題或未知問題的代碼 Binding: Absent or Unknown Problems - IPS (required): 應填入所綁定值集中的其中一個代碼。 ele-1: All FHIR elements must have a @value or children | ||||
coding:sct | S | 0..1 | CodingTW | 此為SNOMED CT診斷代碼,若機構已有購買相關授權,亦可使用。 Binding: SNOMED CT診斷代碼值集 (required): 應填入所綁定值集中的其中一個代碼。 ele-1: All FHIR elements must have a @value or children | ||||
text | SΣ | 0..1 | string | 概念的文字表示法 ele-1: All FHIR elements must have a @value or children | ||||
bodySite | S | 0..* | CodeableConceptTW | 如果相關請填寫解剖位置 Binding: SNOMEDCTBodyStructures (extensible): 描述解剖位置的代碼。可包括側面;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。 ele-1: All FHIR elements must have a @value or children | ||||
subject | SΣ | 1..1 | Reference(TW Core Patient | Group) | 誰有此病情、問題或診斷? ele-1: All FHIR elements must have a @value or children | ||||
encounter | Σ | 0..1 | Reference(TW Core Encounter) | 作為病情、問題或診斷紀錄的一部分的就醫(Encounter)紀錄 ele-1: All FHIR elements must have a @value or children | ||||
onset[x] | SΣ | 0..1 | 估計的或實際的日期、日期—時間或年齡。 ele-1: All FHIR elements must have a @value or children | |||||
onsetDateTime | dateTime | |||||||
abatement[x] | SC | 0..1 | 何時解決/緩解 ele-1: All FHIR elements must have a @value or children | |||||
abatementDateTime | dateTime | |||||||
recordedDate | Σ | 0..1 | dateTime | 記錄的日期 ele-1: All FHIR elements must have a @value or children | ||||
recorder | Σ | 0..1 | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | TW Core RelatedPerson) | 誰記錄此病情、問題或診斷 ele-1: All FHIR elements must have a @value or children | ||||
asserter | SΣ | 0..1 | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | TW Core RelatedPerson) | 聲稱有此病情、問題或診斷的人 ele-1: All FHIR elements must have a @value or children | ||||
stage | C | 0..* | BackboneElement | 分期(stage)/分級(grade),通常是正式的評估。 con-1: Stage SHALL have summary or assessment ele-1: All FHIR elements must have a @value or children | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
summary | 0..1 | CodeableConceptTW | 簡單的摘要(特定疾病)。 Binding: ConditionStage (extensible): 描述病情、問題或診斷分期的代碼(例如:癌症分期)。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。 ele-1: All FHIR elements must have a @value or children | |||||
assessment | C | 0..* | Reference(ClinicalImpression | TW Core DiagnosticReport | TW Core Observation Laboratory Result | TW Core Observation Vital Signs) | 正式的評估記錄 ele-1: All FHIR elements must have a @value or children | ||||
type | 0..1 | CodeableConceptTW | 分期的種類 Binding: ConditionStageType (extensible): 病情、問題或診斷分期種類的代碼(如臨床或病理);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。 ele-1: All FHIR elements must have a @value or children | |||||
evidence | C | 0..* | BackboneElement | 支持的證據 con-2: evidence SHALL have code or details ele-1: All FHIR elements must have a @value or children | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
code | 0..* | CodeableConceptTW | 表現/症狀 Binding: ManifestationAndSymptomCodes (extensible): 病情、問題或診斷的表現或症狀之代碼;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。 ele-1: All FHIR elements must have a @value or children | |||||
detail | ΣC | 0..* | Reference(Resource) | 在其他地方找到的支持資訊 ele-1: All FHIR elements must have a @value or children | ||||
note | S | 0..* | Annotation | 關於此Condition的附加資訊 ele-1: All FHIR elements must have a @value or children | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Condition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard
| ||||
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | ||||
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | ||||
Condition.category | extensible | ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard | ||||
Condition.severity | extensible | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | ||||
Condition.code | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Condition.code.coding:icd10-cm-2023 | required | TW2023ICD10CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2023-tw from this IG | ||||
Condition.code.coding:icd10-cm-2021 | required | TW2021ICD10CM (a valid code from 臺灣健保署2021年中文版ICD-10-CM)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2021-tw from this IG | ||||
Condition.code.coding:icd10-cm-2014 | required | TW2014ICD10CM (a valid code from 臺灣健保署2014年中文版ICD-10-CM)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2014-tw from this IG | ||||
Condition.code.coding:icd9-cm-2001 | required | TW2001ICD9CM (a valid code from 臺灣健保署2001年中文版ICD-9-CM)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw from this IG | ||||
Condition.code.coding:absentOrUnknownProblem | required | AbsentOrUnknownProblemsUvIpshttp://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips | ||||
Condition.code.coding:sct | required | TWConditionCodeSCThttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw from this IG | ||||
Condition.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Condition.stage.summary | extensible | ConditionStagehttp://hl7.org/fhir/ValueSet/condition-stage from the FHIR Standard | ||||
Condition.stage.type | extensible | ConditionStageTypehttp://hl7.org/fhir/ValueSet/condition-stage-type from the FHIR Standard | ||||
Condition.evidence.code | extensible | ManifestationAndSymptomCodeshttp://hl7.org/fhir/ValueSet/manifestation-or-symptom from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
con-1 | error | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.exists() | |
con-2 | error | Condition.evidence | evidence SHALL have code or details : code.exists() or detail.exists() | |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | 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 | Condition | 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 | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | 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() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | Condition | 有關病情、問題或診斷的詳細資訊 con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error | ||||
id | Σ | 0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的Condition紀錄,通常又稱為邏輯性ID。 | ||||
meta | Σ | 0..1 | Meta | 此Condition Resource的metadata | ||||
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Condition 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。
Example Value: zh-TW | |||||
text | 0..1 | Narrative | Condition Resource之內容摘要以供人閱讀 | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | 此病情、問題或診斷的外部識別碼 | ||||
clinicalStatus | S | 1..1 | CodeableConceptTW | active | recurrence | relapse | inactive | remission | resolved ,病情、問題或診斷的臨床狀態。 Binding: ConditionClinicalStatusCodes (required): 應填入所綁定值集中的其中一個代碼。 | ||||
verificationStatus | S | 0..1 | CodeableConceptTW | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error ,支持或拒絕病情、問題或診斷的臨床狀態的驗證狀態。 Binding: ConditionVerificationStatus (required): 應填入所綁定值集中的其中一個代碼。 | ||||
category | S | 1..1 | CodeableConceptTW | problem-list-item | encounter-diagnosis ,指定病情、問題或診斷的類別。 Binding: ConditionCategoryCodes (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。 | ||||
severity | S | 0..1 | CodeableConceptTW | 病情、問題或診斷的主觀嚴重程度 Binding: Condition/DiagnosisSeverity (extensible): 臨床醫生對病情、問題或診斷嚴重程度的主觀評價;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。 | ||||
code | S | 0..1 | CodeableConceptTW | 病情、問題或診斷的識別 Binding: Condition/Problem/DiagnosisCodes (example): 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 | ||||
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 | |||||
Slices for coding | S | 0..* | CodingTW | 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 Slice: Unordered, Open by pattern:$this | ||||
coding:icd10-cm-2023 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (required) | ||||
coding:icd10-cm-2021 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2021年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:icd10-cm-2014 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:icd9-cm-2001 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required) | ||||
coding:absentOrUnknownProblem | S | 0..1 | CodingTW | 不存在的問題或未知問題的代碼 Binding: Absent or Unknown Problems - IPS (required): 應填入所綁定值集中的其中一個代碼。 | ||||
coding:sct | S | 0..1 | CodingTW | 此為SNOMED CT診斷代碼,若機構已有購買相關授權,亦可使用。 Binding: SNOMED CT診斷代碼值集 (required): 應填入所綁定值集中的其中一個代碼。 | ||||
text | SΣ | 0..1 | string | 概念的文字表示法 | ||||
bodySite | S | 0..* | CodeableConceptTW | 如果相關請填寫解剖位置 Binding: SNOMEDCTBodyStructures (extensible): 描述解剖位置的代碼。可包括側面;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。 | ||||
subject | SΣ | 1..1 | Reference(TW Core Patient | Group) | 誰有此病情、問題或診斷? | ||||
encounter | Σ | 0..1 | Reference(TW Core Encounter) | 作為病情、問題或診斷紀錄的一部分的就醫(Encounter)紀錄 | ||||
onset[x] | SΣ | 0..1 | 估計的或實際的日期、日期—時間或年齡。 | |||||
onsetDateTime | dateTime S | |||||||
onsetAge | Age | |||||||
onsetPeriod | Period | |||||||
onsetRange | Range | |||||||
onsetString | string | |||||||
abatement[x] | SC | 0..1 | 何時解決/緩解 | |||||
abatementDateTime | dateTime S | |||||||
abatementAge | Age | |||||||
abatementPeriod | Period | |||||||
abatementRange | Range | |||||||
abatementString | string | |||||||
recordedDate | Σ | 0..1 | dateTime | 記錄的日期 | ||||
recorder | Σ | 0..1 | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | TW Core RelatedPerson) | 誰記錄此病情、問題或診斷 | ||||
asserter | SΣ | 0..1 | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | TW Core RelatedPerson) | 聲稱有此病情、問題或診斷的人 | ||||
stage | C | 0..* | BackboneElement | 分期(stage)/分級(grade),通常是正式的評估。 con-1: Stage SHALL have summary or assessment | ||||
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 | ||||
summary | 0..1 | CodeableConceptTW | 簡單的摘要(特定疾病)。 Binding: ConditionStage (extensible): 描述病情、問題或診斷分期的代碼(例如:癌症分期)。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。 | |||||
assessment | C | 0..* | Reference(ClinicalImpression | TW Core DiagnosticReport | TW Core Observation Laboratory Result | TW Core Observation Vital Signs) | 正式的評估記錄 | ||||
type | 0..1 | CodeableConceptTW | 分期的種類 Binding: ConditionStageType (extensible): 病情、問題或診斷分期種類的代碼(如臨床或病理);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。 | |||||
evidence | C | 0..* | BackboneElement | 支持的證據 con-2: evidence SHALL have code or details | ||||
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 | 0..* | CodeableConceptTW | 表現/症狀 Binding: ManifestationAndSymptomCodes (extensible): 病情、問題或診斷的表現或症狀之代碼;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。 | |||||
detail | ΣC | 0..* | Reference(Resource) | 在其他地方找到的支持資訊 | ||||
note | S | 0..* | Annotation | 關於此Condition的附加資訊 | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Condition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard
| ||||
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | ||||
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | ||||
Condition.category | extensible | ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard | ||||
Condition.severity | extensible | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | ||||
Condition.code | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Condition.code.coding:icd10-cm-2023 | required | TW2023ICD10CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2023-tw from this IG | ||||
Condition.code.coding:icd10-cm-2021 | required | TW2021ICD10CM (a valid code from 臺灣健保署2021年中文版ICD-10-CM)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2021-tw from this IG | ||||
Condition.code.coding:icd10-cm-2014 | required | TW2014ICD10CM (a valid code from 臺灣健保署2014年中文版ICD-10-CM)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2014-tw from this IG | ||||
Condition.code.coding:icd9-cm-2001 | required | TW2001ICD9CM (a valid code from 臺灣健保署2001年中文版ICD-9-CM)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw from this IG | ||||
Condition.code.coding:absentOrUnknownProblem | required | AbsentOrUnknownProblemsUvIpshttp://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips | ||||
Condition.code.coding:sct | required | TWConditionCodeSCThttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw from this IG | ||||
Condition.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Condition.stage.summary | extensible | ConditionStagehttp://hl7.org/fhir/ValueSet/condition-stage from the FHIR Standard | ||||
Condition.stage.type | extensible | ConditionStageTypehttp://hl7.org/fhir/ValueSet/condition-stage-type from the FHIR Standard | ||||
Condition.evidence.code | extensible | ManifestationAndSymptomCodeshttp://hl7.org/fhir/ValueSet/manifestation-or-symptom from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
con-1 | error | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.exists() | |
con-2 | error | Condition.evidence | evidence SHALL have code or details : code.exists() or detail.exists() | |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | 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 | Condition | 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 | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | 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 Condition
Summary
Mandatory: 2 elements
Must-Support: 17 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Condition
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | 0..* | Condition | 有關病情、問題或診斷的詳細資訊 | |||||
id | 0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的Condition紀錄,通常又稱為邏輯性ID。 | |||||
meta | 0..1 | Meta | 此Condition Resource的metadata | |||||
implicitRules | 0..1 | uri | 創建此內容所依據的一組規則 | |||||
language | 0..1 | code | 用以表述Condition 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。
Example Value: zh-TW | |||||
text | 0..1 | Narrative | Condition Resource之內容摘要以供人閱讀 | |||||
identifier | 0..* | Identifier | 此病情、問題或診斷的外部識別碼 | |||||
clinicalStatus | S | 1..1 | CodeableConceptTW | active | recurrence | relapse | inactive | remission | resolved ,病情、問題或診斷的臨床狀態。 Binding: ConditionClinicalStatusCodes (required): 應填入所綁定值集中的其中一個代碼。 | ||||
verificationStatus | S | 0..1 | CodeableConceptTW | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error ,支持或拒絕病情、問題或診斷的臨床狀態的驗證狀態。 Binding: ConditionVerificationStatus (required): 應填入所綁定值集中的其中一個代碼。 | ||||
category | S | 1..1 | CodeableConceptTW | problem-list-item | encounter-diagnosis ,指定病情、問題或診斷的類別。 Binding: ConditionCategoryCodes (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。 | ||||
severity | S | 0..1 | CodeableConceptTW | 病情、問題或診斷的主觀嚴重程度 Binding: Condition/DiagnosisSeverity (extensible): 臨床醫生對病情、問題或診斷嚴重程度的主觀評價;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。 | ||||
code | S | 0..1 | CodeableConceptTW | 病情、問題或診斷的識別 Binding: Condition/Problem/DiagnosisCodes (example): 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 | ||||
Slices for coding | 0..* | CodingTW | 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 Slice: Unordered, Open by pattern:$this | |||||
coding:icd10-cm-2023 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (required) | ||||
coding:icd10-cm-2021 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2021年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:icd10-cm-2014 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:icd9-cm-2001 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required) | ||||
coding:absentOrUnknownProblem | S | 0..1 | CodingTW | 不存在的問題或未知問題的代碼 Binding: Absent or Unknown Problems - IPS (required): 應填入所綁定值集中的其中一個代碼。 | ||||
coding:sct | S | 0..1 | CodingTW | 此為SNOMED CT診斷代碼,若機構已有購買相關授權,亦可使用。 Binding: SNOMED CT診斷代碼值集 (required): 應填入所綁定值集中的其中一個代碼。 | ||||
bodySite | S | 0..* | CodeableConceptTW | 如果相關請填寫解剖位置 Binding: SNOMEDCTBodyStructures (extensible): 描述解剖位置的代碼。可包括側面;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。 | ||||
subject | S | 1..1 | Reference(TW Core Patient | Group) | 誰有此病情、問題或診斷? | ||||
encounter | 0..1 | Reference(TW Core Encounter) | 作為病情、問題或診斷紀錄的一部分的就醫(Encounter)紀錄 | |||||
onset[x] | S | 0..1 | 估計的或實際的日期、日期—時間或年齡。 | |||||
onsetDateTime | dateTime S | |||||||
onsetAge | Age | |||||||
onsetPeriod | Period | |||||||
onsetRange | Range | |||||||
onsetString | string | |||||||
abatement[x] | S | 0..1 | 何時解決/緩解 | |||||
abatementDateTime | dateTime S | |||||||
abatementAge | Age | |||||||
abatementPeriod | Period | |||||||
abatementRange | Range | |||||||
abatementString | string | |||||||
recordedDate | 0..1 | dateTime | 記錄的日期 | |||||
recorder | 0..1 | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | TW Core RelatedPerson) | 誰記錄此病情、問題或診斷 | |||||
asserter | S | 0..1 | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | TW Core RelatedPerson) | 聲稱有此病情、問題或診斷的人 | ||||
stage | 0..* | BackboneElement | 分期(stage)/分級(grade),通常是正式的評估。 | |||||
summary | 0..1 | CodeableConceptTW | 簡單的摘要(特定疾病)。 Binding: ConditionStage (extensible): 描述病情、問題或診斷分期的代碼(例如:癌症分期)。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。 | |||||
assessment | 0..* | Reference(ClinicalImpression | TW Core DiagnosticReport | TW Core Observation Laboratory Result | TW Core Observation Vital Signs) | 正式的評估記錄 | |||||
type | 0..1 | CodeableConceptTW | 分期的種類 Binding: ConditionStageType (extensible): 病情、問題或診斷分期種類的代碼(如臨床或病理);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。 | |||||
evidence | 0..* | BackboneElement | 支持的證據 | |||||
code | 0..* | CodeableConceptTW | 表現/症狀 Binding: ManifestationAndSymptomCodes (extensible): 病情、問題或診斷的表現或症狀之代碼;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。 | |||||
detail | 0..* | Reference(Resource) | 在其他地方找到的支持資訊 | |||||
note | S | 0..* | Annotation | 關於此Condition的附加資訊 | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Condition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard
| ||||
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | ||||
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | ||||
Condition.category | extensible | ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard | ||||
Condition.severity | extensible | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | ||||
Condition.code | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Condition.code.coding:icd10-cm-2023 | required | TW2023ICD10CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2023-tw from this IG | ||||
Condition.code.coding:icd10-cm-2021 | required | TW2021ICD10CM (a valid code from 臺灣健保署2021年中文版ICD-10-CM)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2021-tw from this IG | ||||
Condition.code.coding:icd10-cm-2014 | required | TW2014ICD10CM (a valid code from 臺灣健保署2014年中文版ICD-10-CM)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2014-tw from this IG | ||||
Condition.code.coding:icd9-cm-2001 | required | TW2001ICD9CM (a valid code from 臺灣健保署2001年中文版ICD-9-CM)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw from this IG | ||||
Condition.code.coding:absentOrUnknownProblem | required | AbsentOrUnknownProblemsUvIpshttp://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips | ||||
Condition.code.coding:sct | required | TWConditionCodeSCThttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw from this IG | ||||
Condition.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Condition.stage.summary | extensible | ConditionStagehttp://hl7.org/fhir/ValueSet/condition-stage from the FHIR Standard | ||||
Condition.stage.type | extensible | ConditionStageTypehttp://hl7.org/fhir/ValueSet/condition-stage-type from the FHIR Standard | ||||
Condition.evidence.code | extensible | ManifestationAndSymptomCodeshttp://hl7.org/fhir/ValueSet/manifestation-or-symptom from the FHIR Standard |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | Condition | 有關病情、問題或診斷的詳細資訊 con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management | ||||
id | Σ | 0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的Condition紀錄,通常又稱為邏輯性ID。 | ||||
meta | Σ | 0..1 | Meta | 此Condition Resource的metadata ele-1: All FHIR elements must have a @value or children | ||||
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 ele-1: All FHIR elements must have a @value or children | ||||
language | 0..1 | code | 用以表述Condition 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。
ele-1: All FHIR elements must have a @value or children Example Value: zh-TW | |||||
text | 0..1 | Narrative | Condition Resource之內容摘要以供人閱讀 ele-1: All FHIR elements must have a @value or children | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
identifier | Σ | 0..* | Identifier | 此病情、問題或診斷的外部識別碼 ele-1: All FHIR elements must have a @value or children | ||||
clinicalStatus | S | 1..1 | CodeableConceptTW | active | recurrence | relapse | inactive | remission | resolved ,病情、問題或診斷的臨床狀態。 Binding: ConditionClinicalStatusCodes (required): 應填入所綁定值集中的其中一個代碼。 ele-1: All FHIR elements must have a @value or children | ||||
verificationStatus | S | 0..1 | CodeableConceptTW | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error ,支持或拒絕病情、問題或診斷的臨床狀態的驗證狀態。 Binding: ConditionVerificationStatus (required): 應填入所綁定值集中的其中一個代碼。 ele-1: All FHIR elements must have a @value or children | ||||
category | S | 1..1 | CodeableConceptTW | problem-list-item | encounter-diagnosis ,指定病情、問題或診斷的類別。 Binding: ConditionCategoryCodes (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。 ele-1: All FHIR elements must have a @value or children | ||||
severity | S | 0..1 | CodeableConceptTW | 病情、問題或診斷的主觀嚴重程度 Binding: Condition/DiagnosisSeverity (extensible): 臨床醫生對病情、問題或診斷嚴重程度的主觀評價;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。 ele-1: All FHIR elements must have a @value or children | ||||
code | S | 0..1 | CodeableConceptTW | 病情、問題或診斷的識別 Binding: Condition/Problem/DiagnosisCodes (example): 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 ele-1: All FHIR elements must have a @value or children | ||||
Slices for coding | S | 0..* | CodingTW | 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 Slice: Unordered, Open by pattern:$this ele-1: All FHIR elements must have a @value or children | ||||
coding:icd10-cm-2023 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (required) ele-1: All FHIR elements must have a @value or children | ||||
coding:icd10-cm-2021 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2021年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。 ele-1: All FHIR elements must have a @value or children | ||||
coding:icd10-cm-2014 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。 ele-1: All FHIR elements must have a @value or children | ||||
coding:icd9-cm-2001 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required) ele-1: All FHIR elements must have a @value or children | ||||
coding:absentOrUnknownProblem | S | 0..1 | CodingTW | 不存在的問題或未知問題的代碼 Binding: Absent or Unknown Problems - IPS (required): 應填入所綁定值集中的其中一個代碼。 ele-1: All FHIR elements must have a @value or children | ||||
coding:sct | S | 0..1 | CodingTW | 此為SNOMED CT診斷代碼,若機構已有購買相關授權,亦可使用。 Binding: SNOMED CT診斷代碼值集 (required): 應填入所綁定值集中的其中一個代碼。 ele-1: All FHIR elements must have a @value or children | ||||
text | SΣ | 0..1 | string | 概念的文字表示法 ele-1: All FHIR elements must have a @value or children | ||||
bodySite | S | 0..* | CodeableConceptTW | 如果相關請填寫解剖位置 Binding: SNOMEDCTBodyStructures (extensible): 描述解剖位置的代碼。可包括側面;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。 ele-1: All FHIR elements must have a @value or children | ||||
subject | SΣ | 1..1 | Reference(TW Core Patient | Group) | 誰有此病情、問題或診斷? ele-1: All FHIR elements must have a @value or children | ||||
encounter | Σ | 0..1 | Reference(TW Core Encounter) | 作為病情、問題或診斷紀錄的一部分的就醫(Encounter)紀錄 ele-1: All FHIR elements must have a @value or children | ||||
onset[x] | SΣ | 0..1 | 估計的或實際的日期、日期—時間或年齡。 ele-1: All FHIR elements must have a @value or children | |||||
onsetDateTime | dateTime | |||||||
abatement[x] | SC | 0..1 | 何時解決/緩解 ele-1: All FHIR elements must have a @value or children | |||||
abatementDateTime | dateTime | |||||||
recordedDate | Σ | 0..1 | dateTime | 記錄的日期 ele-1: All FHIR elements must have a @value or children | ||||
recorder | Σ | 0..1 | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | TW Core RelatedPerson) | 誰記錄此病情、問題或診斷 ele-1: All FHIR elements must have a @value or children | ||||
asserter | SΣ | 0..1 | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | TW Core RelatedPerson) | 聲稱有此病情、問題或診斷的人 ele-1: All FHIR elements must have a @value or children | ||||
stage | C | 0..* | BackboneElement | 分期(stage)/分級(grade),通常是正式的評估。 con-1: Stage SHALL have summary or assessment ele-1: All FHIR elements must have a @value or children | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
summary | 0..1 | CodeableConceptTW | 簡單的摘要(特定疾病)。 Binding: ConditionStage (extensible): 描述病情、問題或診斷分期的代碼(例如:癌症分期)。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。 ele-1: All FHIR elements must have a @value or children | |||||
assessment | C | 0..* | Reference(ClinicalImpression | TW Core DiagnosticReport | TW Core Observation Laboratory Result | TW Core Observation Vital Signs) | 正式的評估記錄 ele-1: All FHIR elements must have a @value or children | ||||
type | 0..1 | CodeableConceptTW | 分期的種類 Binding: ConditionStageType (extensible): 病情、問題或診斷分期種類的代碼(如臨床或病理);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。 ele-1: All FHIR elements must have a @value or children | |||||
evidence | C | 0..* | BackboneElement | 支持的證據 con-2: evidence SHALL have code or details ele-1: All FHIR elements must have a @value or children | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
code | 0..* | CodeableConceptTW | 表現/症狀 Binding: ManifestationAndSymptomCodes (extensible): 病情、問題或診斷的表現或症狀之代碼;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。 ele-1: All FHIR elements must have a @value or children | |||||
detail | ΣC | 0..* | Reference(Resource) | 在其他地方找到的支持資訊 ele-1: All FHIR elements must have a @value or children | ||||
note | S | 0..* | Annotation | 關於此Condition的附加資訊 ele-1: All FHIR elements must have a @value or children | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Condition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard
| ||||
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | ||||
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | ||||
Condition.category | extensible | ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard | ||||
Condition.severity | extensible | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | ||||
Condition.code | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Condition.code.coding:icd10-cm-2023 | required | TW2023ICD10CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2023-tw from this IG | ||||
Condition.code.coding:icd10-cm-2021 | required | TW2021ICD10CM (a valid code from 臺灣健保署2021年中文版ICD-10-CM)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2021-tw from this IG | ||||
Condition.code.coding:icd10-cm-2014 | required | TW2014ICD10CM (a valid code from 臺灣健保署2014年中文版ICD-10-CM)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2014-tw from this IG | ||||
Condition.code.coding:icd9-cm-2001 | required | TW2001ICD9CM (a valid code from 臺灣健保署2001年中文版ICD-9-CM)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw from this IG | ||||
Condition.code.coding:absentOrUnknownProblem | required | AbsentOrUnknownProblemsUvIpshttp://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips | ||||
Condition.code.coding:sct | required | TWConditionCodeSCThttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw from this IG | ||||
Condition.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Condition.stage.summary | extensible | ConditionStagehttp://hl7.org/fhir/ValueSet/condition-stage from the FHIR Standard | ||||
Condition.stage.type | extensible | ConditionStageTypehttp://hl7.org/fhir/ValueSet/condition-stage-type from the FHIR Standard | ||||
Condition.evidence.code | extensible | ManifestationAndSymptomCodeshttp://hl7.org/fhir/ValueSet/manifestation-or-symptom from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
con-1 | error | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.exists() | |
con-2 | error | Condition.evidence | evidence SHALL have code or details : code.exists() or detail.exists() | |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | 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 | Condition | 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 | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | 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() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | Condition | 有關病情、問題或診斷的詳細資訊 con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error | ||||
id | Σ | 0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的Condition紀錄,通常又稱為邏輯性ID。 | ||||
meta | Σ | 0..1 | Meta | 此Condition Resource的metadata | ||||
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Condition 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。
Example Value: zh-TW | |||||
text | 0..1 | Narrative | Condition Resource之內容摘要以供人閱讀 | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | 此病情、問題或診斷的外部識別碼 | ||||
clinicalStatus | S | 1..1 | CodeableConceptTW | active | recurrence | relapse | inactive | remission | resolved ,病情、問題或診斷的臨床狀態。 Binding: ConditionClinicalStatusCodes (required): 應填入所綁定值集中的其中一個代碼。 | ||||
verificationStatus | S | 0..1 | CodeableConceptTW | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error ,支持或拒絕病情、問題或診斷的臨床狀態的驗證狀態。 Binding: ConditionVerificationStatus (required): 應填入所綁定值集中的其中一個代碼。 | ||||
category | S | 1..1 | CodeableConceptTW | problem-list-item | encounter-diagnosis ,指定病情、問題或診斷的類別。 Binding: ConditionCategoryCodes (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。 | ||||
severity | S | 0..1 | CodeableConceptTW | 病情、問題或診斷的主觀嚴重程度 Binding: Condition/DiagnosisSeverity (extensible): 臨床醫生對病情、問題或診斷嚴重程度的主觀評價;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。 | ||||
code | S | 0..1 | CodeableConceptTW | 病情、問題或診斷的識別 Binding: Condition/Problem/DiagnosisCodes (example): 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 | ||||
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 | |||||
Slices for coding | S | 0..* | CodingTW | 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 Slice: Unordered, Open by pattern:$this | ||||
coding:icd10-cm-2023 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (required) | ||||
coding:icd10-cm-2021 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2021年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:icd10-cm-2014 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:icd9-cm-2001 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required) | ||||
coding:absentOrUnknownProblem | S | 0..1 | CodingTW | 不存在的問題或未知問題的代碼 Binding: Absent or Unknown Problems - IPS (required): 應填入所綁定值集中的其中一個代碼。 | ||||
coding:sct | S | 0..1 | CodingTW | 此為SNOMED CT診斷代碼,若機構已有購買相關授權,亦可使用。 Binding: SNOMED CT診斷代碼值集 (required): 應填入所綁定值集中的其中一個代碼。 | ||||
text | SΣ | 0..1 | string | 概念的文字表示法 | ||||
bodySite | S | 0..* | CodeableConceptTW | 如果相關請填寫解剖位置 Binding: SNOMEDCTBodyStructures (extensible): 描述解剖位置的代碼。可包括側面;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。 | ||||
subject | SΣ | 1..1 | Reference(TW Core Patient | Group) | 誰有此病情、問題或診斷? | ||||
encounter | Σ | 0..1 | Reference(TW Core Encounter) | 作為病情、問題或診斷紀錄的一部分的就醫(Encounter)紀錄 | ||||
onset[x] | SΣ | 0..1 | 估計的或實際的日期、日期—時間或年齡。 | |||||
onsetDateTime | dateTime S | |||||||
onsetAge | Age | |||||||
onsetPeriod | Period | |||||||
onsetRange | Range | |||||||
onsetString | string | |||||||
abatement[x] | SC | 0..1 | 何時解決/緩解 | |||||
abatementDateTime | dateTime S | |||||||
abatementAge | Age | |||||||
abatementPeriod | Period | |||||||
abatementRange | Range | |||||||
abatementString | string | |||||||
recordedDate | Σ | 0..1 | dateTime | 記錄的日期 | ||||
recorder | Σ | 0..1 | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | TW Core RelatedPerson) | 誰記錄此病情、問題或診斷 | ||||
asserter | SΣ | 0..1 | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | TW Core RelatedPerson) | 聲稱有此病情、問題或診斷的人 | ||||
stage | C | 0..* | BackboneElement | 分期(stage)/分級(grade),通常是正式的評估。 con-1: Stage SHALL have summary or assessment | ||||
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 | ||||
summary | 0..1 | CodeableConceptTW | 簡單的摘要(特定疾病)。 Binding: ConditionStage (extensible): 描述病情、問題或診斷分期的代碼(例如:癌症分期)。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。 | |||||
assessment | C | 0..* | Reference(ClinicalImpression | TW Core DiagnosticReport | TW Core Observation Laboratory Result | TW Core Observation Vital Signs) | 正式的評估記錄 | ||||
type | 0..1 | CodeableConceptTW | 分期的種類 Binding: ConditionStageType (extensible): 病情、問題或診斷分期種類的代碼(如臨床或病理);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。 | |||||
evidence | C | 0..* | BackboneElement | 支持的證據 con-2: evidence SHALL have code or details | ||||
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 | 0..* | CodeableConceptTW | 表現/症狀 Binding: ManifestationAndSymptomCodes (extensible): 病情、問題或診斷的表現或症狀之代碼;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。 | |||||
detail | ΣC | 0..* | Reference(Resource) | 在其他地方找到的支持資訊 | ||||
note | S | 0..* | Annotation | 關於此Condition的附加資訊 | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Condition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard
| ||||
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | ||||
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | ||||
Condition.category | extensible | ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard | ||||
Condition.severity | extensible | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | ||||
Condition.code | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Condition.code.coding:icd10-cm-2023 | required | TW2023ICD10CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2023-tw from this IG | ||||
Condition.code.coding:icd10-cm-2021 | required | TW2021ICD10CM (a valid code from 臺灣健保署2021年中文版ICD-10-CM)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2021-tw from this IG | ||||
Condition.code.coding:icd10-cm-2014 | required | TW2014ICD10CM (a valid code from 臺灣健保署2014年中文版ICD-10-CM)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2014-tw from this IG | ||||
Condition.code.coding:icd9-cm-2001 | required | TW2001ICD9CM (a valid code from 臺灣健保署2001年中文版ICD-9-CM)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw from this IG | ||||
Condition.code.coding:absentOrUnknownProblem | required | AbsentOrUnknownProblemsUvIpshttp://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips | ||||
Condition.code.coding:sct | required | TWConditionCodeSCThttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw from this IG | ||||
Condition.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Condition.stage.summary | extensible | ConditionStagehttp://hl7.org/fhir/ValueSet/condition-stage from the FHIR Standard | ||||
Condition.stage.type | extensible | ConditionStageTypehttp://hl7.org/fhir/ValueSet/condition-stage-type from the FHIR Standard | ||||
Condition.evidence.code | extensible | ManifestationAndSymptomCodeshttp://hl7.org/fhir/ValueSet/manifestation-or-symptom from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
con-1 | error | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.exists() | |
con-2 | error | Condition.evidence | evidence SHALL have code or details : code.exists() or detail.exists() | |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | 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 | Condition | 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 | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | 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 Condition
Summary
Mandatory: 2 elements
Must-Support: 17 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
以下概述了此Profile所需的RESTful FHIR互動功能。有關TW Core IG支援的RESTful互動功能的完整清單,請參閱TW Core Server能力聲明。
建議應該(SHOULD) 支援透過查詢參數 _id
查詢所有Condition:
(如何透過token查詢)
GET [base]/Condition?_id=[id]
GET [base]/Condition/[id]
例子:
(1) GET [base]/Condition?_id=con-example
(2) GET [base]/Condition/con-example
建議應該(SHOULD) 支援透過查詢參數 clinical-status
查詢所有Condition:
(如何透過token查詢)
GET [base]/Condition?clinical-status=[code]
例子:
(1) GET [base]/Condition?clinical-status=remission
建議應該(SHOULD) 支援透過查詢參數 code
查詢所有Condition:
(如何透過token查詢)
GET [base]/Condition?code={system|}[code]
例子:
(1) GET [base]/Condition?code=hhttps://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2021-tw|E08.649
建議應該(SHOULD) 支援透過查詢參數 subject
查詢所有Condition:
(如何透過reference查詢)
GET [base]/Condition?subject={Type/}[id]
例子:
(1) GET [base]/Condition?subject=Patient/pat-example
建議應該(SHOULD) 支援透過查詢參數 onset-date
查詢所有Condition:
(如何透過date查詢)
GET [base]/Condition?onset-date={gt|lt|ge|le}[date]
例子:
(1) GET [base]/Condition?onset-date=gt2022-08-01
建議應該(SHOULD) 支援透過查詢參數 abatement-date
查詢所有Condition:
(如何透過date查詢)
GET [base]/Condition?abatement-date={gt|lt|ge|le}[date]
例子:
(1) GET [base]/Condition?abatement-date=gt2022-08-01
建議應該(SHOULD) 支援透過查詢參數 severity
查詢所有Condition:
(如何透過token查詢)
GET [base]/Condition?severity={system|}[code]
例子:
(1) GET [base]/Condition?severity=http://loinc.org|LA6752-5