臺灣核心實作指引(TW Core IG)
0.3.1 - 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 0.3.1 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: TWCoreDiagnosticReport - Detailed Descriptions

Active as of 2024-11-11

Definitions for the DiagnosticReport-twcore resource profile.

Guidance on how to interpret the contents of this table can be found here

0. DiagnosticReport
Definition

對病人、一群病人、設備和地點、和/或由這些所產生的檢體進行診斷測試的發現與解釋,報告包括臨床情境,如請求和服務提供者的資訊,以及一些混合的不可被中斷的一個或一系列結果、影像、文字和編碼的解釋,以及格式化的診斷報告。

Short診斷報告—由請求資訊、不可被中斷的一個或一系列結果(atomic results)、影像、解釋以及格式化報告所組成。
Comments

這是為了捕捉單一的報告資訊,不適合用於顯示涵蓋多個報告的摘要資訊。例如:此resource沒有為實驗室累積報告格式設計,也沒有為排序的詳細結構化報告設計。

2. DiagnosticReport.id
Definition

resource的邏輯ID,在resource的URL中使用。一旦指定,這個值永遠不會改變。

Short不重複的ID用以識別儲存在特定FHIR Server中的DiagnosticReport紀錄,通常又稱為邏輯性ID。
Comments

一個resource使用新增操作(create operation)提交給伺服器時,此resource沒有id,它的id在resource被創建後由伺器分配/指定。

4. DiagnosticReport.meta
Definition

關於resource的metadata。這是由基礎建設維護的內容。內容的更改可能並不總是與resource的版本更改相關聯。

Short此DiagnosticReport Resource的metadata
6. DiagnosticReport.implicitRules
Definition

構建resource時遵循的一系列規則的參照,在處理內容時必須理解這些規則。通常這是對IG所定義之特殊規則及其他profiles的參照。

Short創建此內容所依據的一組規則
Comments

宣告這套規則限制了內容只能被有限的交易夥伴所理解。這從本質上限制了資料的長期有用性。然而,現有的健康生態體系高度分裂,還沒有準備好以普遍可計算的方式定義、收集和交換資料。只要有可能,實作者和/或規範編寫者應該避免使用這個資料項目。通常在使用時,此URL是對IG的參照,此IG將這些特殊規則與其他profiles、value sets等一起定義為其敘述的一部分。

8. DiagnosticReport.language
Definition

編寫此resource的語言

Short用以表述DiagnosticReport Resource內容的語言。
Comments

提供語言是為了支援索引和可存取性(通常,文字表述轉語音等服務使用此語言標籤)。html lanuage tag適用於此敘述。resource上的語言標籤可用於指定從resource中的資料所產成的其他表述之語言。不是所有的內容都必須使用此語言。不應該假定Resource.language自動適用於敘述。如果指定語言,它也應該被指定在html中的div資料項目(關於xml:lang和html lang屬性之間的關係,見HTML5中的規則)。

BindingThe codes SHOULD be taken from CommonLanguages
(preferred to http://hl7.org/fhir/ValueSet/languages)

人類語言;鼓勵使用CommonLanguages代碼表中的代碼,但不強制一定要使用此代碼表,你也可使用其他代碼表的代碼或單純以文字表示。

Additional BindingsPurpose
AllLanguagesMax Binding
Example<br/><b>Value</b>:zh-TW
10. DiagnosticReport.text
Definition

人可讀的敘述,包含resource的摘要,可用於向人表述resource的內容。敘述不需要對所有的結構化資料進行編碼,但需要包含足夠的細節使人在閱讀敘述時理解「臨床安全性」。resource定義有哪些內容應該在敘述中表示,以確保臨床安全。

ShortDiagnosticReport Resource之內容摘要以供人閱讀
Comments

內嵌(contained)的resource沒有敘述,非內嵌(contained)的resource則 建議應該(SHOULD) 有敘述。有時resource可能只有文字表述,很少或沒有額外的結構化資料(只要滿足所有minOccurs=1的資料項目)。這可能出現在舊系統的資料,當資訊以 「文字表述區塊(text blob) 」的形式被取得,或者文字表述是原始輸入或說明,而編碼資訊稍後再添加。

12. DiagnosticReport.identifier
Definition

由執行者或其他系統指定給該報告的業務用識別碼

Short報告的業務用識別碼
Comments

此識別碼通常由診斷服務提供者的資訊系統指定

NoteThis is a business identifier, not a resource identifier (see discussion)
Requirements

當從來源實驗室查詢此報告以及在FHIR情境之外連接到此報告時,需要知道在應使用什麼識別碼。

14. DiagnosticReport.basedOn
Definition

有關請求的服務的細節

Short此報告是基於什麼服務的請求
Comments

注意:通常每個結果有一個檢驗服務請求,但是在某些情況下,多個檢驗服務請求可以用同一個檢驗結果resource來表示。請注意,也存在一個服務請求導致多個報告的情況。

TypeReference(TW Core CarePlan, ImmunizationRecommendation, TW Core MedicationRequest, NutritionOrder, TW Core ServiceRequest)
Requirements

允許追蹤報告的授權,並追蹤提案/建議是否被採納。

16. DiagnosticReport.status
Definition

診斷報告的狀態

BindingThe codes SHALL be taken from DiagnosticReportStatus
(required to http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1)

診斷報告狀態;應填入所綁定值集中的其中一個代碼

Must Supporttrue
Requirements

診斷服務通常會發布臨時/不完整的報告,有時候也會撤銷之前已發布的報告。

18. DiagnosticReport.category
Definition

對建立報告的臨床科、部門或診斷服務進行分類的代碼(例如:心臟病學、生物化學、血液學、MRI)。主要為了搜尋、排序和顯示時使用。

Short服務類別
Comments

允許使用各種分類方案的多個類別。精細度由值集中的類別概念來定義。可使用DiagnosticReport.code中的metadata和(或)專門術語層次結構進行更細微的過濾。

BindingUnless not suitable, these codes SHALL be taken from DiagnosticServiceSectionCodes
(extensible to http://hl7.org/fhir/ValueSet/diagnostic-service-sections)

診斷報告分類;應填入所綁定值集值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

TypeCodeableConcept(TW CodeableConcept)
Must Supporttrue
20. DiagnosticReport.code
Definition

描述該診斷報告的代碼或名稱

Short此診斷報告的名稱/代碼
BindingThe codes SHOULD be taken from LOINCCodes
(preferred to http://hl7.org/fhir/ValueSet/observation-codes)

鼓勵使用所綁定值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。

TypeCodeableConcept(TW CodeableConcept)
Must Supporttrue
22. DiagnosticReport.code.coding
SlicingThis element introduces a set of slices on DiagnosticReport.code.coding. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • pattern @ $this
  • 24. DiagnosticReport.code.coding:LOINCObservationCode
    Slice NameLOINCObservationCode
    ShortLOINC®為Regenstrief Institute, Inc.維護的檢驗事件描述代碼,可免費使用,可優先選用此代碼。
    Control0..1
    BindingThe codes SHALL be taken from LOINC實驗室檢驗檢查值集
    (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-observation-code)

    應填入所綁定值集中的其中一個代碼。

    Must Supporttrue
    26. DiagnosticReport.code.coding:LOINCObservationCode.system
    Must Supporttrue
    Pattern Valuehttp://loinc.org
    28. DiagnosticReport.code.coding:LOINCObservationCode.code
    Control1..?
    Must Supporttrue
    30. DiagnosticReport.code.coding:TWLaboratoryCategory
    Slice NameTWLaboratoryCategory
    Short此為中央健康保險署(NHI)維護之醫療服務給付項目-檢驗相關代碼,主要針對申報使用,更新頻率相對頻繁,可免費使用,可依情境選用此代碼。
    Control0..1
    BindingThe codes SHALL be taken from 臺灣健保署醫療服務給付項目-檢驗值集
    (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/laboratory-category-tw)

    應填入所綁定值集中的其中一個代碼。

    Must Supporttrue
    32. DiagnosticReport.code.coding:TWLaboratoryCategory.system
    Must Supporttrue
    Pattern Valuehttps://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-service-payment-tw
    34. DiagnosticReport.code.coding:TWLaboratoryCategory.code
    Control1..?
    Must Supporttrue
    36. DiagnosticReport.code.coding:TW2021ICD10PCS
    Slice NameTW2021ICD10PCS
    Short此為臺灣健保署2021年中文版ICD-10-PCS,可免費使用,可依情境選用此代碼。
    Control0..1
    BindingThe codes SHALL be taken from 臺灣健保署2021年中文版ICD-10-PCS值集
    (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw)

    應填入所綁定值集中的其中一個代碼。

    Must Supporttrue
    38. DiagnosticReport.code.coding:TW2021ICD10PCS.system
    Must Supporttrue
    Pattern Valuehttps://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-pcs-2021-tw
    40. DiagnosticReport.code.coding:TW2021ICD10PCS.code
    Control1..?
    Must Supporttrue
    42. DiagnosticReport.code.coding:TW2023ICD10PCS
    Slice NameTW2023ICD10PCS
    Short此為臺灣健保署2023年中文版ICD-10-PCS,可免費使用,可依情境選用此代碼。
    Control0..1
    BindingThe codes SHALL be taken from 臺灣健保署2023年中文版ICD-10-PCS值集
    (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2023-tw)

    應填入所綁定值集中的其中一個代碼。

    Must Supporttrue
    44. DiagnosticReport.code.coding:TW2023ICD10PCS.system
    Must Supporttrue
    Pattern Valuehttps://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-pcs-2023-tw
    46. DiagnosticReport.code.coding:TW2023ICD10PCS.code
    Control1..?
    Must Supporttrue
    48. DiagnosticReport.subject
    Definition

    報告的對象體,通常但不總是病人。然而,診斷服務也對從其他各種來源收集的檢體進行分析。

    Short報告的對象—通常但不總是病人
    Control1..?
    TypeReference(TW Core Patient, Group, Device, TW Core Location)
    Must Supporttrue
    Must Support TypesNo must-support rules about the choice of types/profiles
    Requirements

    必須(SHALL) 知道對象的背景

    50. DiagnosticReport.encounter
    Definition

    此DiagnosticReport所涉及的健康照護事件(例如:病人和健康照護服務提供者的互動)。

    Short請求檢驗時的健康照護事件
    Comments

    這通常是事件發生的就醫,但有些事件可能是在就醫完成之前或之後開始,但仍與就醫的情境有關(如住院前的實驗室檢驗)。

    TypeReference(TW Core Encounter)
    Requirements

    將此服務請求連接就醫(Encounter)情境

    52. DiagnosticReport.effective[x]
    Definition

    觀察值與之相關的時間或時段。當報告的對象是病人時,這通常是處置的時間或檢體採集的時間,但往往不知道日期/時間的來源,只知道日期/時間本身。

    Short與臨床相關的時間/報告的時段
    Comments

    如果對病人進行診斷處置,這就是進行該處置的時間。如果有檢體,可以從檢體採集時間得出診斷相關時間,但檢體資訊並不總是可用,而且檢體和診斷相關時間之間並不總是自動的確切關係。

    TypeChoice of: dateTime, Period
    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Must Support TypesdateTime
    Requirements

    需要知道在病歷的什麼地方儲存檔案/呈現此報告

    54. DiagnosticReport.issued
    Definition

    這個版本的報告提供給健康照護提供者的日期和時間,通常是在報告被審查和核實之後。

    Short此版本完成的日期時間
    Comments

    可能與resource本身的更新時間不同,因為那是紀錄的狀態(可能是第二個副本),而不是發報告的實際時間。

    Must Supporttrue
    Requirements

    臨床醫師需要確認報告的發布日期

    56. DiagnosticReport.performer
    Definition

    負責發此報告的診斷服務

    Short對診斷服務負責者
    Comments

    這不一定是一些混合的不可被中斷的一個或一系列資料項目的來源或解釋結果的實體,它是對臨床報告負責的實體。

    TypeReference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, TW Core CareTeam)
    Must Supporttrue
    Must Support TypesNo must-support rules about the choice of types/profiles
    Requirements

    如果對結果有疑問,需要知道應與誰聯絡;還可能需要追蹤次級資料分析的報告來源。

    58. DiagnosticReport.resultsInterpreter
    Definition

    對報告的結論和解釋負責的健康照護服務提供者或組織

    Short主要結果的解釋者
    Comments

    可能不是對臨床報告負責的同一個實體

    TypeReference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, TW Core CareTeam)
    Requirements

    如果對結果有疑問,需要知道應與誰聯絡;還可能需要追蹤次級資料分析的報告來源。

    60. DiagnosticReport.specimen
    Definition

    關於此診斷報告所依據的檢體的詳細資訊

    Short此報告所依據的檢體
    Comments

    如果在檢驗結果名稱中充分指明檢體的代碼,那麼此附加資料就可能是多餘的。如果有多個檢體,可在每個檢驗檢查或檢驗檢查套組中表示。

    Requirements

    需要能夠報告已收集檢體之資訊,這些資訊是報告的基礎。

    62. DiagnosticReport.result
    Definition

    檢驗檢查為此診斷報告的一部分

    Short檢驗檢查
    Comments

    Observations可包含檢驗檢查值

    TypeReference(TW Core Observation Laboratory Result)
    Must Supporttrue
    Requirements

    需支援單一結果或一組結果,結果分組是隨機但有意義的。

    64. DiagnosticReport.imagingStudy
    Definition

    一個或多個連結指向診斷調查期間進行的任何成像的全部細節。一般情況下,這是由支援DICOM的儀器進行的成像,但這並不是必須的。一個完整的PACS viewer可以使用這些資訊來提供來源影像的視圖。

    Short參照至與診斷報告相關的成像之全部細節
    Comments

    影像檢查(ImagingStudy)和影像(image)資料項目在某種程度上是重疊的—通常,影像(image)資料項目的影像參照清單也會在某個影像檢查(ImagingStudy) resource中找到。然而,每一種都迎合了不同類型的目的的顯示。兩者都不提供,或者兩者都提供。

    TypeReference(TW Core ImagingStudy)
    66. DiagnosticReport.media
    Definition

    與此報告相關的關鍵影像的清單。這些影像一般是在診斷過程中產生的,可以直接是病人的,也可以是經過處理的檢體(即感興趣的玻片)。

    Short與此報告相關的關鍵影像
    Requirements

    許多診斷服務包含將報告中的影像作為服務的一部份

    68. DiagnosticReport.media.comment
    Definition

    關於影像的意見,一般情況下,這是用來解釋為什麼影像被包括在內,或請瀏覽者注意重要特徵。

    Short關於影像的意見(例如:解釋)。
    Comments

    此意見應與影像一起顯示,報告中通常會在其他部分(如結論)對影像內容進行補充討論。

    Requirements

    此報告的健康照護提供者應該對報告中每張影像做出意見

    70. DiagnosticReport.media.link
    Definition

    參照的影像來源

    Short參照的影像來源
    TypeReference(TW Core Media)
    72. DiagnosticReport.conclusion
    Definition

    此診斷報告的簡要及臨床情境的摘要結論(解釋/臆斷)

    Short檢驗結果的臨床結論(解釋)
    Must Supporttrue
    Requirements

    需要能夠提供一個不會在基本結果資料中丟失結論

    74. DiagnosticReport.conclusionCode
    Definition

    代表診斷報告的摘要結論(解釋/臆斷)的一個或多個代碼

    Short檢驗結果的臨床結論的代碼;應填入所綁定值集值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。
    BindingUnless not suitable, these codes SHALL be taken from SNOMEDCTClinicalFindings
    (extensible to http://hl7.org/fhir/ValueSet/clinical-findings)
    TypeCodeableConcept(TW CodeableConcept)
    76. DiagnosticReport.presentedForm
    Definition

    診斷服務發佈之含豐富文字的整個結果,允許多種格式,但它們在語義上 必須(SHALL) 是相同的。

    Short已發佈的整個報告
    Comments

    在這種情況下,「application/pdf 」被推薦為最可靠及最可互操作的格式。

    Requirements

    讓實驗室有能力為臨床真實性提供自己的完全格式化報告

    Guidance on how to interpret the contents of this table can be found here

    0. DiagnosticReport
    Definition

    對病人、一群病人、設備和地點、和/或由這些所產生的檢體進行診斷測試的發現與解釋,報告包括臨床情境,如請求和服務提供者的資訊,以及一些混合的不可被中斷的一個或一系列結果、影像、文字和編碼的解釋,以及格式化的診斷報告。


    The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports.

    Short診斷報告—由請求資訊、不可被中斷的一個或一系列結果(atomic results)、影像、解釋以及格式化報告所組成。A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
    Comments

    這是為了捕捉單一的報告資訊,不適合用於顯示涵蓋多個報告的摘要資訊。例如:此resource沒有為實驗室累積報告格式設計,也沒有為排序的詳細結構化報告設計。


    This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.

    Control0..*
    Is Modifierfalse
    Summaryfalse
    Alternate NamesReport, Test, Result, Results, Labs, Laboratory
    Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
    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 (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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
    dom-6: A resource should have narrative for robust management (text.`div`.exists())
    2. DiagnosticReport.id
    Definition

    resource的邏輯ID,在resource的URL中使用。一旦指定,這個值永遠不會改變。


    The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

    Short不重複的ID用以識別儲存在特定FHIR Server中的DiagnosticReport紀錄,通常又稱為邏輯性ID。Logical id of this artifact
    Comments

    一個resource使用新增操作(create operation)提交給伺服器時,此resource沒有id,它的id在resource被創建後由伺器分配/指定。


    The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

    Control0..1
    Typeidstring
    Is Modifierfalse
    Summarytrue
    4. DiagnosticReport.meta
    Definition

    關於resource的metadata。這是由基礎建設維護的內容。內容的更改可能並不總是與resource的版本更改相關聯。


    The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

    Short此DiagnosticReport Resource的metadataMetadata about the resource
    Control0..1
    TypeMeta
    Is Modifierfalse
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    6. DiagnosticReport.implicitRules
    Definition

    構建resource時遵循的一系列規則的參照,在處理內容時必須理解這些規則。通常這是對IG所定義之特殊規則及其他profiles的參照。


    A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

    Short創建此內容所依據的一組規則A set of rules under which this content was created
    Comments

    宣告這套規則限制了內容只能被有限的交易夥伴所理解。這從本質上限制了資料的長期有用性。然而,現有的健康生態體系高度分裂,還沒有準備好以普遍可計算的方式定義、收集和交換資料。只要有可能,實作者和/或規範編寫者應該避免使用這個資料項目。通常在使用時,此URL是對IG的參照,此IG將這些特殊規則與其他profiles、value sets等一起定義為其敘述的一部分。


    Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

    Control0..1
    Typeuri
    Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    8. DiagnosticReport.language
    Definition

    編寫此resource的語言


    The base language in which the resource is written.

    Short用以表述DiagnosticReport Resource內容的語言。Language of the resource content
    Comments

    提供語言是為了支援索引和可存取性(通常,文字表述轉語音等服務使用此語言標籤)。html lanuage tag適用於此敘述。resource上的語言標籤可用於指定從resource中的資料所產成的其他表述之語言。不是所有的內容都必須使用此語言。不應該假定Resource.language自動適用於敘述。如果指定語言,它也應該被指定在html中的div資料項目(關於xml:lang和html lang屬性之間的關係,見HTML5中的規則)。


    Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

    Control0..1
    BindingThe codes SHOULD be taken from CommonLanguageshttp://hl7.org/fhir/ValueSet/languages
    (preferred to http://hl7.org/fhir/ValueSet/languages)

    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。


    A human language.

    Additional BindingsPurpose
    AllLanguagesMax Binding
    Typecode
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Example<br/><b>Value</b>:zh-TW
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    10. DiagnosticReport.text
    Definition

    人可讀的敘述,包含resource的摘要,可用於向人表述resource的內容。敘述不需要對所有的結構化資料進行編碼,但需要包含足夠的細節使人在閱讀敘述時理解「臨床安全性」。resource定義有哪些內容應該在敘述中表示,以確保臨床安全。


    A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

    ShortDiagnosticReport Resource之內容摘要以供人閱讀Text summary of the resource, for human interpretation
    Comments

    內嵌(contained)的resource沒有敘述,非內嵌(contained)的resource則 建議應該(SHOULD) 有敘述。有時resource可能只有文字表述,很少或沒有額外的結構化資料(只要滿足所有minOccurs=1的資料項目)。這可能出現在舊系統的資料,當資訊以 「文字表述區塊(text blob) 」的形式被取得,或者文字表述是原始輸入或說明,而編碼資訊稍後再添加。


    Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

    Control0..1
    TypeNarrative
    Is Modifierfalse
    Summaryfalse
    Alternate Namesnarrative, html, xhtml, display
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    12. DiagnosticReport.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
    Summaryfalse
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    14. DiagnosticReport.identifier
    Definition

    由執行者或其他系統指定給該報告的業務用識別碼


    Identifiers assigned to this report by the performer or other systems.

    Short報告的業務用識別碼Business identifier for report
    Comments

    此識別碼通常由診斷服務提供者的資訊系統指定


    Usually assigned by the Information System of the diagnostic service provider (filler id).

    NoteThis is a business identifier, not a resource identifier (see discussion)
    Control0..*
    TypeIdentifier
    Is Modifierfalse
    Summarytrue
    Requirements

    當從來源實驗室查詢此報告以及在FHIR情境之外連接到此報告時,需要知道在應使用什麼識別碼。


    Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context.

    Alternate NamesReportID, Filler ID, Placer ID
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    16. DiagnosticReport.basedOn
    Definition

    有關請求的服務的細節


    Details concerning a service requested.

    Short此報告是基於什麼服務的請求What was requested
    Comments

    注意:通常每個結果有一個檢驗服務請求,但是在某些情況下,多個檢驗服務請求可以用同一個檢驗結果resource來表示。請注意,也存在一個服務請求導致多個報告的情況。


    Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports.

    Control0..*
    TypeReference(TW Core CarePlan, ImmunizationRecommendation, TW Core MedicationRequest, NutritionOrder, TW Core ServiceRequest, CarePlan, MedicationRequest, ServiceRequest)
    Is Modifierfalse
    Summaryfalse
    Requirements

    允許追蹤報告的授權,並追蹤提案/建議是否被採納。


    This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon.

    Alternate NamesRequest
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    18. DiagnosticReport.status
    Definition

    診斷報告的狀態


    The status of the diagnostic report.

    Shortregistered | partial | preliminary | final +
    Control1..1
    BindingThe codes SHALL be taken from DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1
    (required to http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1)

    診斷報告狀態;應填入所綁定值集中的其中一個代碼


    The status of the diagnostic report.

    Typecode
    Is Modifiertrue because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Requirements

    診斷服務通常會發布臨時/不完整的報告,有時候也會撤銷之前已發布的報告。


    Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    20. DiagnosticReport.category
    Definition

    對建立報告的臨床科、部門或診斷服務進行分類的代碼(例如:心臟病學、生物化學、血液學、MRI)。主要為了搜尋、排序和顯示時使用。


    A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.

    Short服務類別Service category
    Comments

    允許使用各種分類方案的多個類別。精細度由值集中的類別概念來定義。可使用DiagnosticReport.code中的metadata和(或)專門術語層次結構進行更細微的過濾。


    Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code.

    Control0..*
    This element is affected by the following invariants: ele-1
    BindingUnless not suitable, these codes SHALL be taken from For example codes, see DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections
    (extensible to http://hl7.org/fhir/ValueSet/diagnostic-service-sections)

    診斷報告分類;應填入所綁定值集值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


    Codes for diagnostic service sections.

    TypeCodeableConcept(TW CodeableConcept)
    Is Modifierfalse
    Must Supporttrue
    Alternate NamesDepartment, Sub-department, Service, Discipline
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    22. DiagnosticReport.code
    Definition

    描述該診斷報告的代碼或名稱


    A code or name that describes this diagnostic report.

    Short此診斷報告的名稱/代碼Name/Code for this diagnostic report
    Comments

    Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

    Control1..1
    This element is affected by the following invariants: ele-1
    BindingThe codes SHOULD be taken from LOINCCodeshttp://hl7.org/fhir/ValueSet/report-codes
    (preferred to http://hl7.org/fhir/ValueSet/observation-codes)

    鼓勵使用所綁定值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。


    Codes that describe Diagnostic Reports.

    TypeCodeableConcept(TW CodeableConcept)
    Is Modifierfalse
    Must Supporttrue
    Alternate NamesType
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    24. DiagnosticReport.code.coding
    Definition

    由專門術語系統(terminology system)所定義之代碼的參照


    A reference to a code defined by a terminology system.

    Short由專門術語系統(terminology system)定義的代碼Code defined by a terminology system
    Comments

    代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,例如:SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


    Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

    Control0..*
    This element is affected by the following invariants: ele-1
    TypeCoding(TW Coding)
    Is Modifierfalse
    Must Supporttrue
    Requirements

    允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。


    Allows for alternative encodings within a code system, and translations to other code systems.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    SlicingThis element introduces a set of slices on DiagnosticReport.code.coding. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • pattern @ $this
    • 26. DiagnosticReport.code.coding:LOINCObservationCode
      Slice NameLOINCObservationCode
      Definition

      由專門術語系統(terminology system)所定義之代碼的參照


      A reference to a code defined by a terminology system.

      ShortLOINC®為Regenstrief Institute, Inc.維護的檢驗事件描述代碼,可免費使用,可優先選用此代碼。Code defined by a terminology system
      Comments

      代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,例如:SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


      Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

      Control0..1*
      This element is affected by the following invariants: ele-1
      BindingThe codes SHALL be taken from For codes, see LOINC實驗室檢驗檢查值集
      (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-observation-code)

      應填入所綁定值集中的其中一個代碼。

      TypeCoding(TW Coding)
      Is Modifierfalse
      Must Supporttrue
      Requirements

      允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。


      Allows for alternative encodings within a code system, and translations to other code systems.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      28. DiagnosticReport.code.coding:LOINCObservationCode.system
      Definition

      定義代碼中符號意義的代碼系統識別


      The identification of the code system that defines the meaning of the symbol in the code.

      Short專門術語系統(terminology system)的識別Identity of the terminology system
      Comments

      URI可以是一個OID(urn:oid:...)或一個UUID(urn:uuid:...);OID和UUID 必須(SHALL) 參照HL7 OID註冊中心;否則,URI應該來自HL7的FHIR定義的特殊URI列表,或者它應該參照一些明確建立的系统定義。


      The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

      Control0..1
      Typeuri
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      需要明確說明符號定義的來源


      Need to be unambiguous about the source of the definition of the symbol.

      Pattern Valuehttp://loinc.org
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      30. DiagnosticReport.code.coding:LOINCObservationCode.code
      Definition

      系統定義的語法之符號;符號可能是一個預先定義的代碼,也可能是代碼系統定義的語法中的表達式(如後組合配對/後組合式)。


      A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

      Short系統定義的語法之符號Symbol in syntax defined by the system
      Control10..1
      Typecode
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      需要參照系統中的一個特定代碼


      Need to refer to a particular code in the system.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      32. DiagnosticReport.code.coding:LOINCObservationCode.display
      Definition

      遵循系統的規則以呈現代碼含義的表示法


      A representation of the meaning of the code in the system, following the rules of the system.

      Short由系統定義的表示法Representation defined by the system
      Control0..1
      Typestring
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      需要能為不了解此系統的讀者呈現可讀的代碼含義


      Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      34. DiagnosticReport.code.coding:TWLaboratoryCategory
      Slice NameTWLaboratoryCategory
      Definition

      由專門術語系統(terminology system)所定義之代碼的參照


      A reference to a code defined by a terminology system.

      Short此為中央健康保險署(NHI)維護之醫療服務給付項目-檢驗相關代碼,主要針對申報使用,更新頻率相對頻繁,可免費使用,可依情境選用此代碼。Code defined by a terminology system
      Comments

      代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,例如:SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


      Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

      Control0..1*
      This element is affected by the following invariants: ele-1
      BindingThe codes SHALL be taken from For codes, see 臺灣健保署醫療服務給付項目-檢驗值集
      (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/laboratory-category-tw)

      應填入所綁定值集中的其中一個代碼。

      TypeCoding(TW Coding)
      Is Modifierfalse
      Must Supporttrue
      Requirements

      允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。


      Allows for alternative encodings within a code system, and translations to other code systems.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      36. DiagnosticReport.code.coding:TWLaboratoryCategory.system
      Definition

      定義代碼中符號意義的代碼系統識別


      The identification of the code system that defines the meaning of the symbol in the code.

      Short專門術語系統(terminology system)的識別Identity of the terminology system
      Comments

      URI可以是一個OID(urn:oid:...)或一個UUID(urn:uuid:...);OID和UUID 必須(SHALL) 參照HL7 OID註冊中心;否則,URI應該來自HL7的FHIR定義的特殊URI列表,或者它應該參照一些明確建立的系统定義。


      The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

      Control0..1
      Typeuri
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      需要明確說明符號定義的來源


      Need to be unambiguous about the source of the definition of the symbol.

      Pattern Valuehttps://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-service-payment-tw
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      38. DiagnosticReport.code.coding:TWLaboratoryCategory.code
      Definition

      系統定義的語法之符號;符號可能是一個預先定義的代碼,也可能是代碼系統定義的語法中的表達式(如後組合配對/後組合式)。


      A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

      Short系統定義的語法之符號Symbol in syntax defined by the system
      Control10..1
      Typecode
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      需要參照系統中的一個特定代碼


      Need to refer to a particular code in the system.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      40. DiagnosticReport.code.coding:TWLaboratoryCategory.display
      Definition

      遵循系統的規則以呈現代碼含義的表示法


      A representation of the meaning of the code in the system, following the rules of the system.

      Short由系統定義的表示法Representation defined by the system
      Control0..1
      Typestring
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      需要能為不了解此系統的讀者呈現可讀的代碼含義


      Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      42. DiagnosticReport.code.coding:TW2021ICD10PCS
      Slice NameTW2021ICD10PCS
      Definition

      由專門術語系統(terminology system)所定義之代碼的參照


      A reference to a code defined by a terminology system.

      Short此為臺灣健保署2021年中文版ICD-10-PCS,可免費使用,可依情境選用此代碼。Code defined by a terminology system
      Comments

      代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,例如:SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


      Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

      Control0..1*
      This element is affected by the following invariants: ele-1
      BindingThe codes SHALL be taken from For codes, see 臺灣健保署2021年中文版ICD-10-PCS值集
      (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw)

      應填入所綁定值集中的其中一個代碼。

      TypeCoding(TW Coding)
      Is Modifierfalse
      Must Supporttrue
      Requirements

      允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。


      Allows for alternative encodings within a code system, and translations to other code systems.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      44. DiagnosticReport.code.coding:TW2021ICD10PCS.system
      Definition

      定義代碼中符號意義的代碼系統識別


      The identification of the code system that defines the meaning of the symbol in the code.

      Short專門術語系統(terminology system)的識別Identity of the terminology system
      Comments

      URI可以是一個OID(urn:oid:...)或一個UUID(urn:uuid:...);OID和UUID 必須(SHALL) 參照HL7 OID註冊中心;否則,URI應該來自HL7的FHIR定義的特殊URI列表,或者它應該參照一些明確建立的系统定義。


      The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

      Control0..1
      Typeuri
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      需要明確說明符號定義的來源


      Need to be unambiguous about the source of the definition of the symbol.

      Pattern Valuehttps://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-pcs-2021-tw
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      46. DiagnosticReport.code.coding:TW2021ICD10PCS.code
      Definition

      系統定義的語法之符號;符號可能是一個預先定義的代碼,也可能是代碼系統定義的語法中的表達式(如後組合配對/後組合式)。


      A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

      Short系統定義的語法之符號Symbol in syntax defined by the system
      Control10..1
      Typecode
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      需要參照系統中的一個特定代碼


      Need to refer to a particular code in the system.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      48. DiagnosticReport.code.coding:TW2021ICD10PCS.display
      Definition

      遵循系統的規則以呈現代碼含義的表示法


      A representation of the meaning of the code in the system, following the rules of the system.

      Short由系統定義的表示法Representation defined by the system
      Control0..1
      Typestring
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      需要能為不了解此系統的讀者呈現可讀的代碼含義


      Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      50. DiagnosticReport.code.coding:TW2023ICD10PCS
      Slice NameTW2023ICD10PCS
      Definition

      由專門術語系統(terminology system)所定義之代碼的參照


      A reference to a code defined by a terminology system.

      Short此為臺灣健保署2023年中文版ICD-10-PCS,可免費使用,可依情境選用此代碼。Code defined by a terminology system
      Comments

      代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,例如:SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


      Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

      Control0..1*
      This element is affected by the following invariants: ele-1
      BindingThe codes SHALL be taken from For codes, see 臺灣健保署2023年中文版ICD-10-PCS值集
      (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2023-tw)

      應填入所綁定值集中的其中一個代碼。

      TypeCoding(TW Coding)
      Is Modifierfalse
      Must Supporttrue
      Requirements

      允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。


      Allows for alternative encodings within a code system, and translations to other code systems.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      52. DiagnosticReport.code.coding:TW2023ICD10PCS.system
      Definition

      定義代碼中符號意義的代碼系統識別


      The identification of the code system that defines the meaning of the symbol in the code.

      Short專門術語系統(terminology system)的識別Identity of the terminology system
      Comments

      URI可以是一個OID(urn:oid:...)或一個UUID(urn:uuid:...);OID和UUID 必須(SHALL) 參照HL7 OID註冊中心;否則,URI應該來自HL7的FHIR定義的特殊URI列表,或者它應該參照一些明確建立的系统定義。


      The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

      Control0..1
      Typeuri
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      需要明確說明符號定義的來源


      Need to be unambiguous about the source of the definition of the symbol.

      Pattern Valuehttps://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-pcs-2023-tw
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      54. DiagnosticReport.code.coding:TW2023ICD10PCS.code
      Definition

      系統定義的語法之符號;符號可能是一個預先定義的代碼,也可能是代碼系統定義的語法中的表達式(如後組合配對/後組合式)。


      A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

      Short系統定義的語法之符號Symbol in syntax defined by the system
      Control10..1
      Typecode
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      需要參照系統中的一個特定代碼


      Need to refer to a particular code in the system.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      56. DiagnosticReport.code.coding:TW2023ICD10PCS.display
      Definition

      遵循系統的規則以呈現代碼含義的表示法


      A representation of the meaning of the code in the system, following the rules of the system.

      Short由系統定義的表示法Representation defined by the system
      Control0..1
      Typestring
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      需要能為不了解此系統的讀者呈現可讀的代碼含義


      Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      58. DiagnosticReport.code.text
      Definition

      輸入資料的使用者所見/所選/所說的人類可讀文字表述,和(或)其代表使用者的預期含義。


      A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

      Short概念的文字表示法Plain text representation of the concept
      Comments

      很多時候,此文字表述與其中一個代碼的顯示名稱相同。


      Very often the text is the same as a displayName of one of the codings.

      Control0..1
      Typestring
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      專門術語中的代碼並不總是能捕捉人類使用的細微差別的正確意義,或者根本就沒有合適的代碼;這些情況下,文字表述被用來捕捉來源的全部意義。


      The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      60. DiagnosticReport.subject
      Definition

      報告的對象體,通常但不總是病人。然而,診斷服務也對從其他各種來源收集的檢體進行分析。


      The subject of the report. Usually, but not always, this is a patient. However, diagnostic services also perform analyses on specimens collected from a variety of other sources.

      Short報告的對象—通常但不總是病人The subject of the report - usually, but not always, the patient
      Control10..1
      TypeReference(TW Core Patient, Group, Device, TW Core Location, Patient, Location)
      Is Modifierfalse
      Must Supporttrue
      Must Support TypesNo must-support rules about the choice of types/profiles
      Summarytrue
      Requirements

      必須(SHALL) 知道對象的背景


      SHALL know the subject context.

      Alternate NamesPatient
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      62. DiagnosticReport.encounter
      Definition

      此DiagnosticReport所涉及的健康照護事件(例如:病人和健康照護服務提供者的互動)。


      The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about.

      Short請求檢驗時的健康照護事件Health care event when test ordered
      Comments

      這通常是事件發生的就醫,但有些事件可能是在就醫完成之前或之後開始,但仍與就醫的情境有關(如住院前的實驗室檢驗)。


      This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).

      Control0..1
      TypeReference(TW Core Encounter, Encounter)
      Is Modifierfalse
      Summarytrue
      Requirements

      將此服務請求連接就醫(Encounter)情境


      Links the request to the Encounter context.

      Alternate NamesContext
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      64. DiagnosticReport.effective[x]
      Definition

      觀察值與之相關的時間或時段。當報告的對象是病人時,這通常是處置的時間或檢體採集的時間,但往往不知道日期/時間的來源,只知道日期/時間本身。


      The time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself.

      Short與臨床相關的時間/報告的時段Clinically relevant time/time-period for report
      Comments

      如果對病人進行診斷處置,這就是進行該處置的時間。如果有檢體,可以從檢體採集時間得出診斷相關時間,但檢體資訊並不總是可用,而且檢體和診斷相關時間之間並不總是自動的確切關係。


      If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.

      Control0..1
      TypeChoice of: dateTime, Period
      [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Must Support TypesdateTime
      Summarytrue
      Requirements

      需要知道在病歷的什麼地方儲存檔案/呈現此報告


      Need to know where in the patient history to file/present this report.

      Alternate NamesObservation time, Effective Time, Occurrence
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      66. DiagnosticReport.issued
      Definition

      這個版本的報告提供給健康照護提供者的日期和時間,通常是在報告被審查和核實之後。


      The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified.

      Short此版本完成的日期時間DateTime this version was made
      Comments

      可能與resource本身的更新時間不同,因為那是紀錄的狀態(可能是第二個副本),而不是發報告的實際時間。


      May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.

      Control0..1
      Typeinstant
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      臨床醫師需要確認報告的發布日期


      Clinicians need to be able to check the date that the report was released.

      Alternate NamesDate published, Date Issued, Date Verified
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      68. DiagnosticReport.performer
      Definition

      負責發此報告的診斷服務


      The diagnostic service that is responsible for issuing the report.

      Short對診斷服務負責者Responsible Diagnostic Service
      Comments

      這不一定是一些混合的不可被中斷的一個或一系列資料項目的來源或解釋結果的實體,它是對臨床報告負責的實體。


      This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report.

      Control0..*
      TypeReference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, TW Core CareTeam, Practitioner, PractitionerRole, Organization, CareTeam)
      Is Modifierfalse
      Must Supporttrue
      Must Support TypesNo must-support rules about the choice of types/profiles
      Summarytrue
      Requirements

      如果對結果有疑問,需要知道應與誰聯絡;還可能需要追蹤次級資料分析的報告來源。


      Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.

      Alternate NamesLaboratory, Service, Practitioner, Department, Company, Authorized by, Director
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      70. DiagnosticReport.resultsInterpreter
      Definition

      對報告的結論和解釋負責的健康照護服務提供者或組織


      The practitioner or organization that is responsible for the report's conclusions and interpretations.

      Short主要結果的解釋者Primary result interpreter
      Comments

      可能不是對臨床報告負責的同一個實體


      Might not be the same entity that takes responsibility for the clinical report.

      Control0..*
      TypeReference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, TW Core CareTeam, Practitioner, PractitionerRole, Organization, CareTeam)
      Is Modifierfalse
      Summarytrue
      Requirements

      如果對結果有疑問,需要知道應與誰聯絡;還可能需要追蹤次級資料分析的報告來源。


      Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.

      Alternate NamesAnalyzed by, Reported by
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      72. DiagnosticReport.specimen
      Definition

      關於此診斷報告所依據的檢體的詳細資訊


      Details about the specimens on which this diagnostic report is based.

      Short此報告所依據的檢體Specimens this report is based on
      Comments

      如果在檢驗結果名稱中充分指明檢體的代碼,那麼此附加資料就可能是多餘的。如果有多個檢體,可在每個檢驗檢查或檢驗檢查套組中表示。


      If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group.

      Control0..*
      TypeReference(Specimen)
      Is Modifierfalse
      Summaryfalse
      Requirements

      需要能夠報告已收集檢體之資訊,這些資訊是報告的基礎。


      Need to be able to report information about the collected specimens on which the report is based.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      74. DiagnosticReport.result
      Definition

      檢驗檢查為此診斷報告的一部分


      Observations that are part of this diagnostic report.

      Short檢驗檢查Observations
      Comments

      Observations可包含檢驗檢查值


      Observations can contain observations.

      Control0..*
      TypeReference(TW Core Observation Laboratory Result, Observation)
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Requirements

      需支援單一結果或一組結果,結果分組是隨機但有意義的。


      Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

      Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      76. DiagnosticReport.imagingStudy
      Definition

      一個或多個連結指向診斷調查期間進行的任何成像的全部細節。一般情況下,這是由支援DICOM的儀器進行的成像,但這並不是必須的。一個完整的PACS viewer可以使用這些資訊來提供來源影像的視圖。


      One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images.

      Short參照至與診斷報告相關的成像之全部細節Reference to full details of imaging associated with the diagnostic report
      Comments

      影像檢查(ImagingStudy)和影像(image)資料項目在某種程度上是重疊的—通常,影像(image)資料項目的影像參照清單也會在某個影像檢查(ImagingStudy) resource中找到。然而,每一種都迎合了不同類型的目的的顯示。兩者都不提供,或者兩者都提供。


      ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.

      Control0..*
      TypeReference(TW Core ImagingStudy, ImagingStudy)
      Is Modifierfalse
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      78. DiagnosticReport.media
      Definition

      與此報告相關的關鍵影像的清單。這些影像一般是在診斷過程中產生的,可以直接是病人的,也可以是經過處理的檢體(即感興趣的玻片)。


      A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest).

      Short與此報告相關的關鍵影像Key images associated with this report
      Control0..*
      TypeBackboneElement
      Is Modifierfalse
      Summarytrue
      Requirements

      許多診斷服務包含將報告中的影像作為服務的一部份


      Many diagnostic services include images in the report as part of their service.

      Alternate NamesDICOM, Slides, Scans
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      80. DiagnosticReport.media.modifierExtension
      Definition

      May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

      ShortExtensions that cannot be ignored even if unrecognized
      Comments

      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

      Control0..*
      TypeExtension
      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
      Summarytrue
      Requirements

      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

      Alternate Namesextensions, user content, modifiers
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      82. DiagnosticReport.media.comment
      Definition

      關於影像的意見,一般情況下,這是用來解釋為什麼影像被包括在內,或請瀏覽者注意重要特徵。


      A comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features.

      Short關於影像的意見(例如:解釋)。Comment about the image (e.g. explanation)
      Comments

      此意見應與影像一起顯示,報告中通常會在其他部分(如結論)對影像內容進行補充討論。


      The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion.

      Control0..1
      Typestring
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summaryfalse
      Requirements

      此報告的健康照護提供者應該對報告中每張影像做出意見


      The provider of the report should make a comment about each image included in the report.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      84. DiagnosticReport.media.link
      Definition

      參照的影像來源


      Reference to the image source.

      Short參照的影像來源Reference to the image source
      Control1..1
      TypeReference(TW Core Media, Media)
      Is Modifierfalse
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      86. DiagnosticReport.conclusion
      Definition

      此診斷報告的簡要及臨床情境的摘要結論(解釋/臆斷)


      Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report.

      Short檢驗結果的臨床結論(解釋)Clinical conclusion (interpretation) of test results
      Control0..1
      Typestring
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summaryfalse
      Requirements

      需要能夠提供一個不會在基本結果資料中丟失結論


      Need to be able to provide a conclusion that is not lost among the basic result data.

      Alternate NamesReport
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      88. DiagnosticReport.conclusionCode
      Definition

      代表診斷報告的摘要結論(解釋/臆斷)的一個或多個代碼


      One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report.

      Short檢驗結果的臨床結論的代碼;應填入所綁定值集值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。Codes for the clinical conclusion of test results
      Comments

      Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

      Control0..*
      This element is affected by the following invariants: ele-1
      BindingUnless not suitable, these codes SHALL be taken from For example codes, see SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findings
      (extensible to http://hl7.org/fhir/ValueSet/clinical-findings)
      TypeCodeableConcept(TW CodeableConcept)
      Is Modifierfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      90. DiagnosticReport.presentedForm
      Definition

      診斷服務發佈之含豐富文字的整個結果,允許多種格式,但它們在語義上 必須(SHALL) 是相同的。


      Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent.

      Short已發佈的整個報告Entire report as issued
      Comments

      在這種情況下,「application/pdf 」被推薦為最可靠及最可互操作的格式。


      "application/pdf" is recommended as the most reliable and interoperable in this context.

      Control0..*
      TypeAttachment
      Is Modifierfalse
      Summaryfalse
      Requirements

      讓實驗室有能力為臨床真實性提供自己的完全格式化報告


      Gives laboratory the ability to provide its own fully formatted report for clinical fidelity.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

      Guidance on how to interpret the contents of this table can be found here

      0. DiagnosticReport
      Definition

      對病人、一群病人、設備和地點、和/或由這些所產生的檢體進行診斷測試的發現與解釋,報告包括臨床情境,如請求和服務提供者的資訊,以及一些混合的不可被中斷的一個或一系列結果、影像、文字和編碼的解釋,以及格式化的診斷報告。

      Short診斷報告—由請求資訊、不可被中斷的一個或一系列結果(atomic results)、影像、解釋以及格式化報告所組成。
      Comments

      這是為了捕捉單一的報告資訊,不適合用於顯示涵蓋多個報告的摘要資訊。例如:此resource沒有為實驗室累積報告格式設計,也沒有為排序的詳細結構化報告設計。

      Control0..*
      Is Modifierfalse
      Summaryfalse
      Alternate NamesReport, Test, Result, Results, Labs, Laboratory
      Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
      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 (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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
      dom-6: A resource should have narrative for robust management (text.`div`.exists())
      2. DiagnosticReport.id
      Definition

      resource的邏輯ID,在resource的URL中使用。一旦指定,這個值永遠不會改變。

      Short不重複的ID用以識別儲存在特定FHIR Server中的DiagnosticReport紀錄,通常又稱為邏輯性ID。
      Comments

      一個resource使用新增操作(create operation)提交給伺服器時,此resource沒有id,它的id在resource被創建後由伺器分配/指定。

      Control0..1
      Typeid
      Is Modifierfalse
      Summarytrue
      4. DiagnosticReport.meta
      Definition

      關於resource的metadata。這是由基礎建設維護的內容。內容的更改可能並不總是與resource的版本更改相關聯。

      Short此DiagnosticReport Resource的metadata
      Control0..1
      TypeMeta
      Is Modifierfalse
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      6. DiagnosticReport.implicitRules
      Definition

      構建resource時遵循的一系列規則的參照,在處理內容時必須理解這些規則。通常這是對IG所定義之特殊規則及其他profiles的參照。

      Short創建此內容所依據的一組規則
      Comments

      宣告這套規則限制了內容只能被有限的交易夥伴所理解。這從本質上限制了資料的長期有用性。然而,現有的健康生態體系高度分裂,還沒有準備好以普遍可計算的方式定義、收集和交換資料。只要有可能,實作者和/或規範編寫者應該避免使用這個資料項目。通常在使用時,此URL是對IG的參照,此IG將這些特殊規則與其他profiles、value sets等一起定義為其敘述的一部分。

      Control0..1
      Typeuri
      Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      8. DiagnosticReport.language
      Definition

      編寫此resource的語言

      Short用以表述DiagnosticReport Resource內容的語言。
      Comments

      提供語言是為了支援索引和可存取性(通常,文字表述轉語音等服務使用此語言標籤)。html lanuage tag適用於此敘述。resource上的語言標籤可用於指定從resource中的資料所產成的其他表述之語言。不是所有的內容都必須使用此語言。不應該假定Resource.language自動適用於敘述。如果指定語言,它也應該被指定在html中的div資料項目(關於xml:lang和html lang屬性之間的關係,見HTML5中的規則)。

      Control0..1
      BindingThe codes SHOULD be taken from CommonLanguages
      (preferred to http://hl7.org/fhir/ValueSet/languages)

      人類語言;鼓勵使用CommonLanguages代碼表中的代碼,但不強制一定要使用此代碼表,你也可使用其他代碼表的代碼或單純以文字表示。

      Additional BindingsPurpose
      AllLanguagesMax Binding
      Typecode
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summaryfalse
      Example<br/><b>Value</b>:zh-TW
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      10. DiagnosticReport.text
      Definition

      人可讀的敘述,包含resource的摘要,可用於向人表述resource的內容。敘述不需要對所有的結構化資料進行編碼,但需要包含足夠的細節使人在閱讀敘述時理解「臨床安全性」。resource定義有哪些內容應該在敘述中表示,以確保臨床安全。

      ShortDiagnosticReport Resource之內容摘要以供人閱讀
      Comments

      內嵌(contained)的resource沒有敘述,非內嵌(contained)的resource則 建議應該(SHOULD) 有敘述。有時resource可能只有文字表述,很少或沒有額外的結構化資料(只要滿足所有minOccurs=1的資料項目)。這可能出現在舊系統的資料,當資訊以 「文字表述區塊(text blob) 」的形式被取得,或者文字表述是原始輸入或說明,而編碼資訊稍後再添加。

      Control0..1
      TypeNarrative
      Is Modifierfalse
      Summaryfalse
      Alternate Namesnarrative, html, xhtml, display
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      12. DiagnosticReport.contained
      Definition

      These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

      ShortContained, inline Resources
      Comments

      This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

      Control0..*
      TypeResource
      Is Modifierfalse
      Summaryfalse
      Alternate Namesinline resources, anonymous resources, contained resources
      14. DiagnosticReport.extension
      Definition

      May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

      ShortAdditional content defined by implementations
      Comments

      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

      Control0..*
      TypeExtension
      Is Modifierfalse
      Summaryfalse
      Alternate Namesextensions, user content
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      16. DiagnosticReport.modifierExtension
      Definition

      May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

      ShortExtensions that cannot be ignored
      Comments

      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

      Control0..*
      TypeExtension
      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
      Summaryfalse
      Requirements

      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

      Alternate Namesextensions, user content
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      18. DiagnosticReport.identifier
      Definition

      由執行者或其他系統指定給該報告的業務用識別碼

      Short報告的業務用識別碼
      Comments

      此識別碼通常由診斷服務提供者的資訊系統指定

      NoteThis is a business identifier, not a resource identifier (see discussion)
      Control0..*
      TypeIdentifier
      Is Modifierfalse
      Summarytrue
      Requirements

      當從來源實驗室查詢此報告以及在FHIR情境之外連接到此報告時,需要知道在應使用什麼識別碼。

      Alternate NamesReportID, Filler ID, Placer ID
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      20. DiagnosticReport.basedOn
      Definition

      有關請求的服務的細節

      Short此報告是基於什麼服務的請求
      Comments

      注意:通常每個結果有一個檢驗服務請求,但是在某些情況下,多個檢驗服務請求可以用同一個檢驗結果resource來表示。請注意,也存在一個服務請求導致多個報告的情況。

      Control0..*
      TypeReference(TW Core CarePlan, ImmunizationRecommendation, TW Core MedicationRequest, NutritionOrder, TW Core ServiceRequest)
      Is Modifierfalse
      Summaryfalse
      Requirements

      允許追蹤報告的授權,並追蹤提案/建議是否被採納。

      Alternate NamesRequest
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      22. DiagnosticReport.status
      Definition

      診斷報告的狀態

      Shortregistered | partial | preliminary | final +
      Control1..1
      BindingThe codes SHALL be taken from DiagnosticReportStatus
      (required to http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1)

      診斷報告狀態;應填入所綁定值集中的其中一個代碼

      Typecode
      Is Modifiertrue because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      診斷服務通常會發布臨時/不完整的報告,有時候也會撤銷之前已發布的報告。

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      24. DiagnosticReport.category
      Definition

      對建立報告的臨床科、部門或診斷服務進行分類的代碼(例如:心臟病學、生物化學、血液學、MRI)。主要為了搜尋、排序和顯示時使用。

      Short服務類別
      Comments

      允許使用各種分類方案的多個類別。精細度由值集中的類別概念來定義。可使用DiagnosticReport.code中的metadata和(或)專門術語層次結構進行更細微的過濾。

      Control0..*
      This element is affected by the following invariants: ele-1
      BindingUnless not suitable, these codes SHALL be taken from DiagnosticServiceSectionCodes
      (extensible to http://hl7.org/fhir/ValueSet/diagnostic-service-sections)

      診斷報告分類;應填入所綁定值集值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

      TypeCodeableConcept(TW CodeableConcept)
      Is Modifierfalse
      Must Supporttrue
      Alternate NamesDepartment, Sub-department, Service, Discipline
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      26. DiagnosticReport.code
      Definition

      描述該診斷報告的代碼或名稱

      Short此診斷報告的名稱/代碼
      Comments

      Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

      Control1..1
      This element is affected by the following invariants: ele-1
      BindingThe codes SHOULD be taken from LOINCCodes
      (preferred to http://hl7.org/fhir/ValueSet/observation-codes)

      鼓勵使用所綁定值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。

      TypeCodeableConcept(TW CodeableConcept)
      Is Modifierfalse
      Must Supporttrue
      Alternate NamesType
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      28. DiagnosticReport.code.id
      Definition

      resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。

      Short唯一可識別ID,以供資料項目間相互參照。
      Control0..1
      Typestring
      Is Modifierfalse
      XML FormatIn the XML format, this property is represented as an attribute.
      Summaryfalse
      30. DiagnosticReport.code.extension
      Definition

      擴充的資料項目

      Short擴充的資料項目
      Control0..*
      TypeExtension
      Is Modifierfalse
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      SlicingThis element introduces a set of slices on DiagnosticReport.code.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • value @ url
      • 32. DiagnosticReport.code.coding
        Definition

        由專門術語系統(terminology system)所定義之代碼的參照

        Short由專門術語系統(terminology system)定義的代碼
        Comments

        代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,例如:SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

        Control0..*
        This element is affected by the following invariants: ele-1
        TypeCoding(TW Coding)
        Is Modifierfalse
        Must Supporttrue
        Requirements

        允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        SlicingThis element introduces a set of slices on DiagnosticReport.code.coding. The slices areUnordered and Open, and can be differentiated using the following discriminators:
        • pattern @ $this
        • 34. DiagnosticReport.code.coding:LOINCObservationCode
          Slice NameLOINCObservationCode
          Definition

          由專門術語系統(terminology system)所定義之代碼的參照

          ShortLOINC®為Regenstrief Institute, Inc.維護的檢驗事件描述代碼,可免費使用,可優先選用此代碼。
          Comments

          代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,例如:SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

          Control0..1
          This element is affected by the following invariants: ele-1
          BindingThe codes SHALL be taken from LOINC實驗室檢驗檢查值集
          (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-observation-code)

          應填入所綁定值集中的其中一個代碼。

          TypeCoding(TW Coding)
          Is Modifierfalse
          Must Supporttrue
          Requirements

          允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          36. DiagnosticReport.code.coding:LOINCObservationCode.id
          Definition

          resource中資料項目的唯一ID(用於內部參照),這可以是任何不含空格的字串。

          Short唯一可識別ID,以供資料項目間相互參照。
          Control0..1
          Typestring
          Is Modifierfalse
          XML FormatIn the XML format, this property is represented as an attribute.
          Summaryfalse
          38. DiagnosticReport.code.coding:LOINCObservationCode.extension
          Definition

          可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

          Short擴充的資料項目
          Comments

          無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

          Control0..*
          TypeExtension
          Is Modifierfalse
          Summaryfalse
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          SlicingThis element introduces a set of slices on DiagnosticReport.code.coding.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
          • value @ url
          • 40. DiagnosticReport.code.coding:LOINCObservationCode.system
            Definition

            定義代碼中符號意義的代碼系統識別

            Short專門術語系統(terminology system)的識別
            Comments

            URI可以是一個OID(urn:oid:...)或一個UUID(urn:uuid:...);OID和UUID 必須(SHALL) 參照HL7 OID註冊中心;否則,URI應該來自HL7的FHIR定義的特殊URI列表,或者它應該參照一些明確建立的系统定義。

            Control0..1
            Typeuri
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Must Supporttrue
            Summarytrue
            Requirements

            需要明確說明符號定義的來源

            Pattern Valuehttp://loinc.org
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            42. DiagnosticReport.code.coding:LOINCObservationCode.version
            Definition

            選擇此代碼時使用的代碼系統版本;請注意,一個維護良好的代碼系統不需要版本報告,因為代碼的意義在不同系統版本中是一致的;然而,不能始終保證這點,當不能保證意義一致時, 必須(SHALL) 將版本資訊也一併作交換。

            Short系統的版本—如果相關的話
            Comments

            如果專門術語沒有明確定義應該使用什麼字串來識別代碼系統的版本,建議使用版本正式發布的日期(用FHIR日期格式表示)作為版本日期。

            NoteThis is a business version Id, not a resource version Id (see discussion)
            Control0..1
            Typestring
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            44. DiagnosticReport.code.coding:LOINCObservationCode.code
            Definition

            系統定義的語法之符號;符號可能是一個預先定義的代碼,也可能是代碼系統定義的語法中的表達式(如後組合配對/後組合式)。

            Short系統定義的語法之符號
            Control1..1
            Typecode
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Must Supporttrue
            Summarytrue
            Requirements

            需要參照系統中的一個特定代碼

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            46. DiagnosticReport.code.coding:LOINCObservationCode.display
            Definition

            遵循系統的規則以呈現代碼含義的表示法

            Short由系統定義的表示法
            Control0..1
            Typestring
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Must Supporttrue
            Summarytrue
            Requirements

            需要能為不了解此系統的讀者呈現可讀的代碼含義

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            48. DiagnosticReport.code.coding:LOINCObservationCode.userSelected
            Definition

            表明此編碼是由使用者直接選擇,例如:從可用項目(代碼或顯示名稱)的清單中選擇。

            Short此編碼是否由使用者直接選擇?
            Comments

            在一系列備選方案中,直接選擇的代碼是新翻譯最合適的起點;關於「直接選擇」的確切意義,存在模糊不清之處,可能需要貿易夥伴的同意,以更完整澄清此資料項目的使用及其後果。

            Control0..1
            Typeboolean
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Summarytrue
            Requirements

            已被確定為一個臨床安全準則—此確切的系統/代碼對(code pair)是被明確選擇的,而不是由系統根據一些規則或是程式語言處理判斷。

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            50. DiagnosticReport.code.coding:TWLaboratoryCategory
            Slice NameTWLaboratoryCategory
            Definition

            由專門術語系統(terminology system)所定義之代碼的參照

            Short此為中央健康保險署(NHI)維護之醫療服務給付項目-檢驗相關代碼,主要針對申報使用,更新頻率相對頻繁,可免費使用,可依情境選用此代碼。
            Comments

            代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,例如:SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

            Control0..1
            This element is affected by the following invariants: ele-1
            BindingThe codes SHALL be taken from 臺灣健保署醫療服務給付項目-檢驗值集
            (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/laboratory-category-tw)

            應填入所綁定值集中的其中一個代碼。

            TypeCoding(TW Coding)
            Is Modifierfalse
            Must Supporttrue
            Requirements

            允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            52. DiagnosticReport.code.coding:TWLaboratoryCategory.id
            Definition

            resource中資料項目的唯一ID(用於內部參照),這可以是任何不含空格的字串。

            Short唯一可識別ID,以供資料項目間相互參照。
            Control0..1
            Typestring
            Is Modifierfalse
            XML FormatIn the XML format, this property is represented as an attribute.
            Summaryfalse
            54. DiagnosticReport.code.coding:TWLaboratoryCategory.extension
            Definition

            可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

            Short擴充的資料項目
            Comments

            無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

            Control0..*
            TypeExtension
            Is Modifierfalse
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            SlicingThis element introduces a set of slices on DiagnosticReport.code.coding.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
            • value @ url
            • 56. DiagnosticReport.code.coding:TWLaboratoryCategory.system
              Definition

              定義代碼中符號意義的代碼系統識別

              Short專門術語系統(terminology system)的識別
              Comments

              URI可以是一個OID(urn:oid:...)或一個UUID(urn:uuid:...);OID和UUID 必須(SHALL) 參照HL7 OID註冊中心;否則,URI應該來自HL7的FHIR定義的特殊URI列表,或者它應該參照一些明確建立的系统定義。

              Control0..1
              Typeuri
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Must Supporttrue
              Summarytrue
              Requirements

              需要明確說明符號定義的來源

              Pattern Valuehttps://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-service-payment-tw
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              58. DiagnosticReport.code.coding:TWLaboratoryCategory.version
              Definition

              選擇此代碼時使用的代碼系統版本;請注意,一個維護良好的代碼系統不需要版本報告,因為代碼的意義在不同系統版本中是一致的;然而,不能始終保證這點,當不能保證意義一致時, 必須(SHALL) 將版本資訊也一併作交換。

              Short系統的版本—如果相關的話
              Comments

              如果專門術語沒有明確定義應該使用什麼字串來識別代碼系統的版本,建議使用版本正式發布的日期(用FHIR日期格式表示)作為版本日期。

              NoteThis is a business version Id, not a resource version Id (see discussion)
              Control0..1
              Typestring
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Summarytrue
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              60. DiagnosticReport.code.coding:TWLaboratoryCategory.code
              Definition

              系統定義的語法之符號;符號可能是一個預先定義的代碼,也可能是代碼系統定義的語法中的表達式(如後組合配對/後組合式)。

              Short系統定義的語法之符號
              Control1..1
              Typecode
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Must Supporttrue
              Summarytrue
              Requirements

              需要參照系統中的一個特定代碼

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              62. DiagnosticReport.code.coding:TWLaboratoryCategory.display
              Definition

              遵循系統的規則以呈現代碼含義的表示法

              Short由系統定義的表示法
              Control0..1
              Typestring
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Must Supporttrue
              Summarytrue
              Requirements

              需要能為不了解此系統的讀者呈現可讀的代碼含義

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              64. DiagnosticReport.code.coding:TWLaboratoryCategory.userSelected
              Definition

              表明此編碼是由使用者直接選擇,例如:從可用項目(代碼或顯示名稱)的清單中選擇。

              Short此編碼是否由使用者直接選擇?
              Comments

              在一系列備選方案中,直接選擇的代碼是新翻譯最合適的起點;關於「直接選擇」的確切意義,存在模糊不清之處,可能需要貿易夥伴的同意,以更完整澄清此資料項目的使用及其後果。

              Control0..1
              Typeboolean
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Summarytrue
              Requirements

              已被確定為一個臨床安全準則—此確切的系統/代碼對(code pair)是被明確選擇的,而不是由系統根據一些規則或是程式語言處理判斷。

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              66. DiagnosticReport.code.coding:TW2021ICD10PCS
              Slice NameTW2021ICD10PCS
              Definition

              由專門術語系統(terminology system)所定義之代碼的參照

              Short此為臺灣健保署2021年中文版ICD-10-PCS,可免費使用,可依情境選用此代碼。
              Comments

              代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,例如:SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

              Control0..1
              This element is affected by the following invariants: ele-1
              BindingThe codes SHALL be taken from 臺灣健保署2021年中文版ICD-10-PCS值集
              (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw)

              應填入所綁定值集中的其中一個代碼。

              TypeCoding(TW Coding)
              Is Modifierfalse
              Must Supporttrue
              Requirements

              允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              68. DiagnosticReport.code.coding:TW2021ICD10PCS.id
              Definition

              resource中資料項目的唯一ID(用於內部參照),這可以是任何不含空格的字串。

              Short唯一可識別ID,以供資料項目間相互參照。
              Control0..1
              Typestring
              Is Modifierfalse
              XML FormatIn the XML format, this property is represented as an attribute.
              Summaryfalse
              70. DiagnosticReport.code.coding:TW2021ICD10PCS.extension
              Definition

              可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

              Short擴充的資料項目
              Comments

              無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

              Control0..*
              TypeExtension
              Is Modifierfalse
              Summaryfalse
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
              SlicingThis element introduces a set of slices on DiagnosticReport.code.coding.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
              • value @ url
              • 72. DiagnosticReport.code.coding:TW2021ICD10PCS.system
                Definition

                定義代碼中符號意義的代碼系統識別

                Short專門術語系統(terminology system)的識別
                Comments

                URI可以是一個OID(urn:oid:...)或一個UUID(urn:uuid:...);OID和UUID 必須(SHALL) 參照HL7 OID註冊中心;否則,URI應該來自HL7的FHIR定義的特殊URI列表,或者它應該參照一些明確建立的系统定義。

                Control0..1
                Typeuri
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Must Supporttrue
                Summarytrue
                Requirements

                需要明確說明符號定義的來源

                Pattern Valuehttps://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-pcs-2021-tw
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                74. DiagnosticReport.code.coding:TW2021ICD10PCS.version
                Definition

                選擇此代碼時使用的代碼系統版本;請注意,一個維護良好的代碼系統不需要版本報告,因為代碼的意義在不同系統版本中是一致的;然而,不能始終保證這點,當不能保證意義一致時, 必須(SHALL) 將版本資訊也一併作交換。

                Short系統的版本—如果相關的話
                Comments

                如果專門術語沒有明確定義應該使用什麼字串來識別代碼系統的版本,建議使用版本正式發布的日期(用FHIR日期格式表示)作為版本日期。

                NoteThis is a business version Id, not a resource version Id (see discussion)
                Control0..1
                Typestring
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Summarytrue
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                76. DiagnosticReport.code.coding:TW2021ICD10PCS.code
                Definition

                系統定義的語法之符號;符號可能是一個預先定義的代碼,也可能是代碼系統定義的語法中的表達式(如後組合配對/後組合式)。

                Short系統定義的語法之符號
                Control1..1
                Typecode
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Must Supporttrue
                Summarytrue
                Requirements

                需要參照系統中的一個特定代碼

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                78. DiagnosticReport.code.coding:TW2021ICD10PCS.display
                Definition

                遵循系統的規則以呈現代碼含義的表示法

                Short由系統定義的表示法
                Control0..1
                Typestring
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Must Supporttrue
                Summarytrue
                Requirements

                需要能為不了解此系統的讀者呈現可讀的代碼含義

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                80. DiagnosticReport.code.coding:TW2021ICD10PCS.userSelected
                Definition

                表明此編碼是由使用者直接選擇,例如:從可用項目(代碼或顯示名稱)的清單中選擇。

                Short此編碼是否由使用者直接選擇?
                Comments

                在一系列備選方案中,直接選擇的代碼是新翻譯最合適的起點;關於「直接選擇」的確切意義,存在模糊不清之處,可能需要貿易夥伴的同意,以更完整澄清此資料項目的使用及其後果。

                Control0..1
                Typeboolean
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Summarytrue
                Requirements

                已被確定為一個臨床安全準則—此確切的系統/代碼對(code pair)是被明確選擇的,而不是由系統根據一些規則或是程式語言處理判斷。

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                82. DiagnosticReport.code.coding:TW2023ICD10PCS
                Slice NameTW2023ICD10PCS
                Definition

                由專門術語系統(terminology system)所定義之代碼的參照

                Short此為臺灣健保署2023年中文版ICD-10-PCS,可免費使用,可依情境選用此代碼。
                Comments

                代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,例如:SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

                Control0..1
                This element is affected by the following invariants: ele-1
                BindingThe codes SHALL be taken from 臺灣健保署2023年中文版ICD-10-PCS值集
                (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2023-tw)

                應填入所綁定值集中的其中一個代碼。

                TypeCoding(TW Coding)
                Is Modifierfalse
                Must Supporttrue
                Requirements

                允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                84. DiagnosticReport.code.coding:TW2023ICD10PCS.id
                Definition

                resource中資料項目的唯一ID(用於內部參照),這可以是任何不含空格的字串。

                Short唯一可識別ID,以供資料項目間相互參照。
                Control0..1
                Typestring
                Is Modifierfalse
                XML FormatIn the XML format, this property is represented as an attribute.
                Summaryfalse
                86. DiagnosticReport.code.coding:TW2023ICD10PCS.extension
                Definition

                可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

                Short擴充的資料項目
                Comments

                無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

                Control0..*
                TypeExtension
                Is Modifierfalse
                Summaryfalse
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                SlicingThis element introduces a set of slices on DiagnosticReport.code.coding.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                • value @ url
                • 88. DiagnosticReport.code.coding:TW2023ICD10PCS.system
                  Definition

                  定義代碼中符號意義的代碼系統識別

                  Short專門術語系統(terminology system)的識別
                  Comments

                  URI可以是一個OID(urn:oid:...)或一個UUID(urn:uuid:...);OID和UUID 必須(SHALL) 參照HL7 OID註冊中心;否則,URI應該來自HL7的FHIR定義的特殊URI列表,或者它應該參照一些明確建立的系统定義。

                  Control0..1
                  Typeuri
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Must Supporttrue
                  Summarytrue
                  Requirements

                  需要明確說明符號定義的來源

                  Pattern Valuehttps://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-pcs-2023-tw
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  90. DiagnosticReport.code.coding:TW2023ICD10PCS.version
                  Definition

                  選擇此代碼時使用的代碼系統版本;請注意,一個維護良好的代碼系統不需要版本報告,因為代碼的意義在不同系統版本中是一致的;然而,不能始終保證這點,當不能保證意義一致時, 必須(SHALL) 將版本資訊也一併作交換。

                  Short系統的版本—如果相關的話
                  Comments

                  如果專門術語沒有明確定義應該使用什麼字串來識別代碼系統的版本,建議使用版本正式發布的日期(用FHIR日期格式表示)作為版本日期。

                  NoteThis is a business version Id, not a resource version Id (see discussion)
                  Control0..1
                  Typestring
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Summarytrue
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  92. DiagnosticReport.code.coding:TW2023ICD10PCS.code
                  Definition

                  系統定義的語法之符號;符號可能是一個預先定義的代碼,也可能是代碼系統定義的語法中的表達式(如後組合配對/後組合式)。

                  Short系統定義的語法之符號
                  Control1..1
                  Typecode
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Must Supporttrue
                  Summarytrue
                  Requirements

                  需要參照系統中的一個特定代碼

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  94. DiagnosticReport.code.coding:TW2023ICD10PCS.display
                  Definition

                  遵循系統的規則以呈現代碼含義的表示法

                  Short由系統定義的表示法
                  Control0..1
                  Typestring
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Must Supporttrue
                  Summarytrue
                  Requirements

                  需要能為不了解此系統的讀者呈現可讀的代碼含義

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  96. DiagnosticReport.code.coding:TW2023ICD10PCS.userSelected
                  Definition

                  表明此編碼是由使用者直接選擇,例如:從可用項目(代碼或顯示名稱)的清單中選擇。

                  Short此編碼是否由使用者直接選擇?
                  Comments

                  在一系列備選方案中,直接選擇的代碼是新翻譯最合適的起點;關於「直接選擇」的確切意義,存在模糊不清之處,可能需要貿易夥伴的同意,以更完整澄清此資料項目的使用及其後果。

                  Control0..1
                  Typeboolean
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Summarytrue
                  Requirements

                  已被確定為一個臨床安全準則—此確切的系統/代碼對(code pair)是被明確選擇的,而不是由系統根據一些規則或是程式語言處理判斷。

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  98. DiagnosticReport.code.text
                  Definition

                  輸入資料的使用者所見/所選/所說的人類可讀文字表述,和(或)其代表使用者的預期含義。

                  Short概念的文字表示法
                  Comments

                  很多時候,此文字表述與其中一個代碼的顯示名稱相同。

                  Control0..1
                  Typestring
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Must Supporttrue
                  Summarytrue
                  Requirements

                  專門術語中的代碼並不總是能捕捉人類使用的細微差別的正確意義,或者根本就沒有合適的代碼;這些情況下,文字表述被用來捕捉來源的全部意義。

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  100. DiagnosticReport.subject
                  Definition

                  報告的對象體,通常但不總是病人。然而,診斷服務也對從其他各種來源收集的檢體進行分析。

                  Short報告的對象—通常但不總是病人
                  Control1..1
                  TypeReference(TW Core Patient, Group, Device, TW Core Location)
                  Is Modifierfalse
                  Must Supporttrue
                  Must Support TypesNo must-support rules about the choice of types/profiles
                  Summarytrue
                  Requirements

                  必須(SHALL) 知道對象的背景

                  Alternate NamesPatient
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  102. DiagnosticReport.encounter
                  Definition

                  此DiagnosticReport所涉及的健康照護事件(例如:病人和健康照護服務提供者的互動)。

                  Short請求檢驗時的健康照護事件
                  Comments

                  這通常是事件發生的就醫,但有些事件可能是在就醫完成之前或之後開始,但仍與就醫的情境有關(如住院前的實驗室檢驗)。

                  Control0..1
                  TypeReference(TW Core Encounter)
                  Is Modifierfalse
                  Summarytrue
                  Requirements

                  將此服務請求連接就醫(Encounter)情境

                  Alternate NamesContext
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  104. DiagnosticReport.effective[x]
                  Definition

                  觀察值與之相關的時間或時段。當報告的對象是病人時,這通常是處置的時間或檢體採集的時間,但往往不知道日期/時間的來源,只知道日期/時間本身。

                  Short與臨床相關的時間/報告的時段
                  Comments

                  如果對病人進行診斷處置,這就是進行該處置的時間。如果有檢體,可以從檢體採集時間得出診斷相關時間,但檢體資訊並不總是可用,而且檢體和診斷相關時間之間並不總是自動的確切關係。

                  Control0..1
                  TypeChoice of: dateTime, Period
                  [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Must Supporttrue
                  Must Support TypesdateTime
                  Summarytrue
                  Requirements

                  需要知道在病歷的什麼地方儲存檔案/呈現此報告

                  Alternate NamesObservation time, Effective Time, Occurrence
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  106. DiagnosticReport.issued
                  Definition

                  這個版本的報告提供給健康照護提供者的日期和時間,通常是在報告被審查和核實之後。

                  Short此版本完成的日期時間
                  Comments

                  可能與resource本身的更新時間不同,因為那是紀錄的狀態(可能是第二個副本),而不是發報告的實際時間。

                  Control0..1
                  Typeinstant
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Must Supporttrue
                  Summarytrue
                  Requirements

                  臨床醫師需要確認報告的發布日期

                  Alternate NamesDate published, Date Issued, Date Verified
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  108. DiagnosticReport.performer
                  Definition

                  負責發此報告的診斷服務

                  Short對診斷服務負責者
                  Comments

                  這不一定是一些混合的不可被中斷的一個或一系列資料項目的來源或解釋結果的實體,它是對臨床報告負責的實體。

                  Control0..*
                  TypeReference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, TW Core CareTeam)
                  Is Modifierfalse
                  Must Supporttrue
                  Must Support TypesNo must-support rules about the choice of types/profiles
                  Summarytrue
                  Requirements

                  如果對結果有疑問,需要知道應與誰聯絡;還可能需要追蹤次級資料分析的報告來源。

                  Alternate NamesLaboratory, Service, Practitioner, Department, Company, Authorized by, Director
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  110. DiagnosticReport.resultsInterpreter
                  Definition

                  對報告的結論和解釋負責的健康照護服務提供者或組織

                  Short主要結果的解釋者
                  Comments

                  可能不是對臨床報告負責的同一個實體

                  Control0..*
                  TypeReference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, TW Core CareTeam)
                  Is Modifierfalse
                  Summarytrue
                  Requirements

                  如果對結果有疑問,需要知道應與誰聯絡;還可能需要追蹤次級資料分析的報告來源。

                  Alternate NamesAnalyzed by, Reported by
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  112. DiagnosticReport.specimen
                  Definition

                  關於此診斷報告所依據的檢體的詳細資訊

                  Short此報告所依據的檢體
                  Comments

                  如果在檢驗結果名稱中充分指明檢體的代碼,那麼此附加資料就可能是多餘的。如果有多個檢體,可在每個檢驗檢查或檢驗檢查套組中表示。

                  Control0..*
                  TypeReference(Specimen)
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  需要能夠報告已收集檢體之資訊,這些資訊是報告的基礎。

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  114. DiagnosticReport.result
                  Definition

                  檢驗檢查為此診斷報告的一部分

                  Short檢驗檢查
                  Comments

                  Observations可包含檢驗檢查值

                  Control0..*
                  TypeReference(TW Core Observation Laboratory Result)
                  Is Modifierfalse
                  Must Supporttrue
                  Summaryfalse
                  Requirements

                  需支援單一結果或一組結果,結果分組是隨機但有意義的。

                  Alternate NamesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  116. DiagnosticReport.imagingStudy
                  Definition

                  一個或多個連結指向診斷調查期間進行的任何成像的全部細節。一般情況下,這是由支援DICOM的儀器進行的成像,但這並不是必須的。一個完整的PACS viewer可以使用這些資訊來提供來源影像的視圖。

                  Short參照至與診斷報告相關的成像之全部細節
                  Comments

                  影像檢查(ImagingStudy)和影像(image)資料項目在某種程度上是重疊的—通常,影像(image)資料項目的影像參照清單也會在某個影像檢查(ImagingStudy) resource中找到。然而,每一種都迎合了不同類型的目的的顯示。兩者都不提供,或者兩者都提供。

                  Control0..*
                  TypeReference(TW Core ImagingStudy)
                  Is Modifierfalse
                  Summaryfalse
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  118. DiagnosticReport.media
                  Definition

                  與此報告相關的關鍵影像的清單。這些影像一般是在診斷過程中產生的,可以直接是病人的,也可以是經過處理的檢體(即感興趣的玻片)。

                  Short與此報告相關的關鍵影像
                  Control0..*
                  TypeBackboneElement
                  Is Modifierfalse
                  Summarytrue
                  Requirements

                  許多診斷服務包含將報告中的影像作為服務的一部份

                  Alternate NamesDICOM, Slides, Scans
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  120. DiagnosticReport.media.id
                  Definition

                  Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                  ShortUnique id for inter-element referencing
                  Control0..1
                  Typestring
                  Is Modifierfalse
                  XML FormatIn the XML format, this property is represented as an attribute.
                  Summaryfalse
                  122. DiagnosticReport.media.extension
                  Definition

                  May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                  ShortAdditional content defined by implementations
                  Comments

                  There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                  Control0..*
                  TypeExtension
                  Is Modifierfalse
                  Summaryfalse
                  Alternate Namesextensions, user content
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  124. DiagnosticReport.media.modifierExtension
                  Definition

                  May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                  Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                  ShortExtensions that cannot be ignored even if unrecognized
                  Comments

                  There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                  Control0..*
                  TypeExtension
                  Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                  Summarytrue
                  Requirements

                  Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                  Alternate Namesextensions, user content, modifiers
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  126. DiagnosticReport.media.comment
                  Definition

                  關於影像的意見,一般情況下,這是用來解釋為什麼影像被包括在內,或請瀏覽者注意重要特徵。

                  Short關於影像的意見(例如:解釋)。
                  Comments

                  此意見應與影像一起顯示,報告中通常會在其他部分(如結論)對影像內容進行補充討論。

                  Control0..1
                  Typestring
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Summaryfalse
                  Requirements

                  此報告的健康照護提供者應該對報告中每張影像做出意見

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  128. DiagnosticReport.media.link
                  Definition

                  參照的影像來源

                  Short參照的影像來源
                  Control1..1
                  TypeReference(TW Core Media)
                  Is Modifierfalse
                  Summarytrue
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  130. DiagnosticReport.conclusion
                  Definition

                  此診斷報告的簡要及臨床情境的摘要結論(解釋/臆斷)

                  Short檢驗結果的臨床結論(解釋)
                  Control0..1
                  Typestring
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Must Supporttrue
                  Summaryfalse
                  Requirements

                  需要能夠提供一個不會在基本結果資料中丟失結論

                  Alternate NamesReport
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  132. DiagnosticReport.conclusionCode
                  Definition

                  代表診斷報告的摘要結論(解釋/臆斷)的一個或多個代碼

                  Short檢驗結果的臨床結論的代碼;應填入所綁定值集值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。
                  Comments

                  Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

                  Control0..*
                  This element is affected by the following invariants: ele-1
                  BindingUnless not suitable, these codes SHALL be taken from SNOMEDCTClinicalFindings
                  (extensible to http://hl7.org/fhir/ValueSet/clinical-findings)
                  TypeCodeableConcept(TW CodeableConcept)
                  Is Modifierfalse
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  134. DiagnosticReport.presentedForm
                  Definition

                  診斷服務發佈之含豐富文字的整個結果,允許多種格式,但它們在語義上 必須(SHALL) 是相同的。

                  Short已發佈的整個報告
                  Comments

                  在這種情況下,「application/pdf 」被推薦為最可靠及最可互操作的格式。

                  Control0..*
                  TypeAttachment
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  讓實驗室有能力為臨床真實性提供自己的完全格式化報告

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))