臺灣核心實作指引(TW Core IG)
0.3.2 - Ci-Build Trial Use

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

Resource Profile: TW Core Condition

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。

Resource Condition - 內容

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。

範圍與使用

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。

  • 失業
  • 缺乏交通工具(或其他障礙)
  • 易跌倒
  • 暴露於傳染病
  • 家族心血管疾病史
  • 對癌症的恐懼
  • 安裝心臟起搏器
  • 截肢-BKA
  • 旅行到某國後的茲卡病毒風險
  • 曾經吸煙者
  • 計劃旅行到某國(需要接種疫苗)
  • 交通事故
  • 病人曾經進行過冠狀動脈搭橋手術

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)。

界限與關聯

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:

Formal Views of Profile Content

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

This structure is derived from Condition

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Condition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severityextensibleCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Condition.code.coding:icd10-cm-2023requiredTW2023ICD10CM
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2023-tw
from this IG
Condition.code.coding:icd10-cm-2021requiredTW2021ICD10CM (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-2014requiredTW2014ICD10CM (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-2001requiredTW2001ICD9CM (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:absentOrUnknownProblemrequiredAbsentOrUnknownProblemsUvIps
http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips
Condition.code.coding:sctrequiredTWConditionCodeSCT
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw
from this IG
Condition.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Condition.stage.summaryextensibleConditionStage
http://hl7.org/fhir/ValueSet/condition-stage
from the FHIR Standard
Condition.stage.typeextensibleConditionStageType
http://hl7.org/fhir/ValueSet/condition-stage-type
from the FHIR Standard
Condition.evidence.codeextensibleManifestationAndSymptomCodes
http://hl7.org/fhir/ValueSet/manifestation-or-symptom
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Condition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severityextensibleCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Condition.code.coding:icd10-cm-2023requiredTW2023ICD10CM
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2023-tw
from this IG
Condition.code.coding:icd10-cm-2021requiredTW2021ICD10CM (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-2014requiredTW2014ICD10CM (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-2001requiredTW2001ICD9CM (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:absentOrUnknownProblemrequiredAbsentOrUnknownProblemsUvIps
http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips
Condition.code.coding:sctrequiredTWConditionCodeSCT
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw
from this IG
Condition.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Condition.stage.summaryextensibleConditionStage
http://hl7.org/fhir/ValueSet/condition-stage
from the FHIR Standard
Condition.stage.typeextensibleConditionStageType
http://hl7.org/fhir/ValueSet/condition-stage-type
from the FHIR Standard
Condition.evidence.codeextensibleManifestationAndSymptomCodes
http://hl7.org/fhir/ValueSet/manifestation-or-symptom
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
con-1errorCondition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
con-2errorCondition.evidenceevidence SHALL have code or details
: code.exists() or detail.exists()
con-3best practiceConditionCondition.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-4errorConditionIf 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-5errorConditionCondition.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-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceConditionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Condition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severityextensibleCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Condition.code.coding:icd10-cm-2023requiredTW2023ICD10CM
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2023-tw
from this IG
Condition.code.coding:icd10-cm-2021requiredTW2021ICD10CM (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-2014requiredTW2014ICD10CM (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-2001requiredTW2001ICD9CM (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:absentOrUnknownProblemrequiredAbsentOrUnknownProblemsUvIps
http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips
Condition.code.coding:sctrequiredTWConditionCodeSCT
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw
from this IG
Condition.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Condition.stage.summaryextensibleConditionStage
http://hl7.org/fhir/ValueSet/condition-stage
from the FHIR Standard
Condition.stage.typeextensibleConditionStageType
http://hl7.org/fhir/ValueSet/condition-stage-type
from the FHIR Standard
Condition.evidence.codeextensibleManifestationAndSymptomCodes
http://hl7.org/fhir/ValueSet/manifestation-or-symptom
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
con-1errorCondition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
con-2errorCondition.evidenceevidence SHALL have code or details
: code.exists() or detail.exists()
con-3best practiceConditionCondition.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-4errorConditionIf 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-5errorConditionCondition.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-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceConditionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from Condition

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Condition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severityextensibleCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Condition.code.coding:icd10-cm-2023requiredTW2023ICD10CM
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2023-tw
from this IG
Condition.code.coding:icd10-cm-2021requiredTW2021ICD10CM (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-2014requiredTW2014ICD10CM (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-2001requiredTW2001ICD9CM (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:absentOrUnknownProblemrequiredAbsentOrUnknownProblemsUvIps
http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips
Condition.code.coding:sctrequiredTWConditionCodeSCT
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw
from this IG
Condition.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Condition.stage.summaryextensibleConditionStage
http://hl7.org/fhir/ValueSet/condition-stage
from the FHIR Standard
Condition.stage.typeextensibleConditionStageType
http://hl7.org/fhir/ValueSet/condition-stage-type
from the FHIR Standard
Condition.evidence.codeextensibleManifestationAndSymptomCodes
http://hl7.org/fhir/ValueSet/manifestation-or-symptom
from the FHIR Standard

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Condition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severityextensibleCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Condition.code.coding:icd10-cm-2023requiredTW2023ICD10CM
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2023-tw
from this IG
Condition.code.coding:icd10-cm-2021requiredTW2021ICD10CM (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-2014requiredTW2014ICD10CM (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-2001requiredTW2001ICD9CM (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:absentOrUnknownProblemrequiredAbsentOrUnknownProblemsUvIps
http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips
Condition.code.coding:sctrequiredTWConditionCodeSCT
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw
from this IG
Condition.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Condition.stage.summaryextensibleConditionStage
http://hl7.org/fhir/ValueSet/condition-stage
from the FHIR Standard
Condition.stage.typeextensibleConditionStageType
http://hl7.org/fhir/ValueSet/condition-stage-type
from the FHIR Standard
Condition.evidence.codeextensibleManifestationAndSymptomCodes
http://hl7.org/fhir/ValueSet/manifestation-or-symptom
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
con-1errorCondition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
con-2errorCondition.evidenceevidence SHALL have code or details
: code.exists() or detail.exists()
con-3best practiceConditionCondition.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-4errorConditionIf 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-5errorConditionCondition.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-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceConditionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Condition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severityextensibleCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Condition.code.coding:icd10-cm-2023requiredTW2023ICD10CM
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2023-tw
from this IG
Condition.code.coding:icd10-cm-2021requiredTW2021ICD10CM (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-2014requiredTW2014ICD10CM (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-2001requiredTW2001ICD9CM (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:absentOrUnknownProblemrequiredAbsentOrUnknownProblemsUvIps
http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips
Condition.code.coding:sctrequiredTWConditionCodeSCT
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw
from this IG
Condition.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Condition.stage.summaryextensibleConditionStage
http://hl7.org/fhir/ValueSet/condition-stage
from the FHIR Standard
Condition.stage.typeextensibleConditionStageType
http://hl7.org/fhir/ValueSet/condition-stage-type
from the FHIR Standard
Condition.evidence.codeextensibleManifestationAndSymptomCodes
http://hl7.org/fhir/ValueSet/manifestation-or-symptom
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
con-1errorCondition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
con-2errorCondition.evidenceevidence SHALL have code or details
: code.exists() or detail.exists()
con-3best practiceConditionCondition.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-4errorConditionIf 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-5errorConditionCondition.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-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceConditionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron

Notes:

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

建議應該支援以下查詢參數:

  1. 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

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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