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
Active as of 2024-10-22 |
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)。 | ||||
Binding | The 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。
| ||||
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。 | ||||
Short | DiagnosticReport 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 | ||||
Note | This 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。 | ||||
Type | Reference(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 | ||||
Binding | The 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 Support | true | ||||
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。 | ||||
Binding | Unless 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。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Must Support | true | ||||
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 | ||||
Binding | The 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。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Must Support | true | ||||
22. DiagnosticReport.code.coding | |||||
Slicing | This element introduces a set of slices on DiagnosticReport.code.coding . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
24. DiagnosticReport.code.coding:LOINCObservationCode | |||||
Slice Name | LOINCObservationCode | ||||
Short | LOINC®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。 | ||||
Control | 0..1 | ||||
Binding | The 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 Support | true | ||||
26. DiagnosticReport.code.coding:LOINCObservationCode.system | |||||
Must Support | true | ||||
Pattern Value | http://loinc.org | ||||
28. DiagnosticReport.code.coding:LOINCObservationCode.code | |||||
Control | 1..? | ||||
Must Support | true | ||||
30. DiagnosticReport.code.coding:TWLaboratoryCategory | |||||
Slice Name | TWLaboratoryCategory | ||||
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。 | ||||
Control | 0..1 | ||||
Binding | The 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 Support | true | ||||
32. DiagnosticReport.code.coding:TWLaboratoryCategory.system | |||||
Must Support | true | ||||
Pattern Value | https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-service-payment-tw | ||||
34. DiagnosticReport.code.coding:TWLaboratoryCategory.code | |||||
Control | 1..? | ||||
Must Support | true | ||||
36. DiagnosticReport.code.coding:TW2021ICD10PCS | |||||
Slice Name | TW2021ICD10PCS | ||||
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。 | ||||
Control | 0..1 | ||||
Binding | The 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 Support | true | ||||
38. DiagnosticReport.code.coding:TW2021ICD10PCS.system | |||||
Must Support | true | ||||
Pattern Value | https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-pcs-2021-tw | ||||
40. DiagnosticReport.code.coding:TW2021ICD10PCS.code | |||||
Control | 1..? | ||||
Must Support | true | ||||
42. DiagnosticReport.code.coding:TW2023ICD10PCS | |||||
Slice Name | TW2023ICD10PCS | ||||
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。 | ||||
Control | 0..1 | ||||
Binding | The 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 Support | true | ||||
44. DiagnosticReport.code.coding:TW2023ICD10PCS.system | |||||
Must Support | true | ||||
Pattern Value | https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-pcs-2023-tw | ||||
46. DiagnosticReport.code.coding:TW2023ICD10PCS.code | |||||
Control | 1..? | ||||
Must Support | true | ||||
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 | ||||
Control | 1..? | ||||
Type | Reference(TW Core Patient, Group, Device, TW Core Location) | ||||
Must Support | true | ||||
Must Support Types | No 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)。 | ||||
Type | Reference(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。 | ||||
Type | Choice of: dateTime, Period | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Must Support Types | dateTime | ||||
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 Support | true | ||||
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。 | ||||
Type | Reference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, TW Core CareTeam) | ||||
Must Support | true | ||||
Must Support Types | No 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 | ||||
Type | Reference(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 | ||||
Type | Reference(TW Core Observation Laboratory Result) | ||||
Must Support | true | ||||
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。 | ||||
Type | Reference(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 | ||||
Type | Reference(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 Support | true | ||||
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。 | ||||
Binding | Unless not suitable, these codes SHALL be taken from SNOMEDCTClinicalFindings (extensible to http://hl7.org/fhir/ValueSet/clinical-findings ) | ||||
Type | CodeableConcept(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. | ||||
Control | 0..* | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | Report, Test, Result, Results, Labs, Laboratory | ||||
Invariants | dom-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. | ||||
Control | 0..1 | ||||
Type | idstring | ||||
Is Modifier | false | ||||
Summary | true | ||||
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 | ||||
Control | 0..1 | ||||
Type | Meta | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-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. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | true 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 Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-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). | ||||
Control | 0..1 | ||||
Binding | The 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.
| ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Example | <br/><b>Value</b>:zh-TW | ||||
Invariants | ele-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. | ||||
Short | DiagnosticReport 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. | ||||
Control | 0..1 | ||||
Type | Narrative | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | narrative, html, xhtml, display | ||||
Invariants | ele-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). | ||||
Short | Extensions 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them | ||||
Summary | false | ||||
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 Names | extensions, user content | ||||
Invariants | ele-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). | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 0..* | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | true | ||||
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 Names | ReportID, Filler ID, Placer ID | ||||
Invariants | ele-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. | ||||
Control | 0..* | ||||
Type | Reference(TW Core CarePlan, ImmunizationRecommendation, TW Core MedicationRequest, NutritionOrder, TW Core ServiceRequest, CarePlan, MedicationRequest, ServiceRequest) | ||||
Is Modifier | false | ||||
Summary | false | ||||
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 Names | Request | ||||
Invariants | ele-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. | ||||
Short | registered | partial | preliminary | final + | ||||
Control | 1..1 | ||||
Binding | The 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. | ||||
Type | code | ||||
Is Modifier | true 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 Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
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. | ||||
Invariants | ele-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. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | Unless 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. | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Alternate Names | Department, Sub-department, Service, Discipline | ||||
Invariants | ele-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. | ||||
Control | 1..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The 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. | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Alternate Names | Type | ||||
Invariants | ele-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. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
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. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
Slicing | This element introduces a set of slices on DiagnosticReport.code.coding . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
26. DiagnosticReport.code.coding:LOINCObservationCode | |||||
Slice Name | LOINCObservationCode | ||||
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 | LOINC®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. | ||||
Control | 0..1* This element is affected by the following invariants: ele-1 | ||||
Binding | The 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。 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
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. | ||||
Invariants | ele-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. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
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 Value | http://loinc.org | ||||
Invariants | ele-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 | ||||
Control | 10..1 | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
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. | ||||
Invariants | ele-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 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
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. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
34. DiagnosticReport.code.coding:TWLaboratoryCategory | |||||
Slice Name | TWLaboratoryCategory | ||||
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. | ||||
Control | 0..1* This element is affected by the following invariants: ele-1 | ||||
Binding | The 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。 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
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. | ||||
Invariants | ele-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. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
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 Value | https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-service-payment-tw | ||||
Invariants | ele-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 | ||||
Control | 10..1 | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
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. | ||||
Invariants | ele-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 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
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. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
42. DiagnosticReport.code.coding:TW2021ICD10PCS | |||||
Slice Name | TW2021ICD10PCS | ||||
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. | ||||
Control | 0..1* This element is affected by the following invariants: ele-1 | ||||
Binding | The 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。 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
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. | ||||
Invariants | ele-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. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
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 Value | https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-pcs-2021-tw | ||||
Invariants | ele-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 | ||||
Control | 10..1 | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
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. | ||||
Invariants | ele-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 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
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. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
50. DiagnosticReport.code.coding:TW2023ICD10PCS | |||||
Slice Name | TW2023ICD10PCS | ||||
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. | ||||
Control | 0..1* This element is affected by the following invariants: ele-1 | ||||
Binding | The 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。 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
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. | ||||
Invariants | ele-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. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
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 Value | https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-pcs-2023-tw | ||||
Invariants | ele-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 | ||||
Control | 10..1 | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
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. | ||||
Invariants | ele-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 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
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. | ||||
Invariants | ele-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. | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
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. | ||||
Invariants | ele-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 | ||||
Control | 10..1 | ||||
Type | Reference(TW Core Patient, Group, Device, TW Core Location, Patient, Location) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Must Support Types | No must-support rules about the choice of types/profiles | ||||
Summary | true | ||||
Requirements | 必須(SHALL) 知道對象的背景 SHALL know the subject context. | ||||
Alternate Names | Patient | ||||
Invariants | ele-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). | ||||
Control | 0..1 | ||||
Type | Reference(TW Core Encounter, Encounter) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | 將此服務請求連接就醫(Encounter)情境 Links the request to the Encounter context. | ||||
Alternate Names | Context | ||||
Invariants | ele-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. | ||||
Control | 0..1 | ||||
Type | Choice of: dateTime, Period | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Must Support Types | dateTime | ||||
Summary | true | ||||
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 Names | Observation time, Effective Time, Occurrence | ||||
Invariants | ele-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. | ||||
Control | 0..1 | ||||
Type | instant | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
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 Names | Date published, Date Issued, Date Verified | ||||
Invariants | ele-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. | ||||
Control | 0..* | ||||
Type | Reference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, TW Core CareTeam, Practitioner, PractitionerRole, Organization, CareTeam) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Must Support Types | No must-support rules about the choice of types/profiles | ||||
Summary | true | ||||
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 Names | Laboratory, Service, Practitioner, Department, Company, Authorized by, Director | ||||
Invariants | ele-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. | ||||
Control | 0..* | ||||
Type | Reference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, TW Core CareTeam, Practitioner, PractitionerRole, Organization, CareTeam) | ||||
Is Modifier | false | ||||
Summary | true | ||||
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 Names | Analyzed by, Reported by | ||||
Invariants | ele-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. | ||||
Control | 0..* | ||||
Type | Reference(Specimen) | ||||
Is Modifier | false | ||||
Summary | false | ||||
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. | ||||
Invariants | ele-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. | ||||
Control | 0..* | ||||
Type | Reference(TW Core Observation Laboratory Result, Observation) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
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 Names | Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer | ||||
Invariants | ele-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. | ||||
Control | 0..* | ||||
Type | Reference(TW Core ImagingStudy, ImagingStudy) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-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 | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | true | ||||
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 Names | DICOM, Slides, Scans | ||||
Invariants | ele-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). | ||||
Short | Extensions 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
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 Names | extensions, user content, modifiers | ||||
Invariants | ele-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. | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
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. | ||||
Invariants | ele-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 | ||||
Control | 1..1 | ||||
Type | Reference(TW Core Media, Media) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-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 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | false | ||||
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 Names | Report | ||||
Invariants | ele-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. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | Unless 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 ) | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-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. | ||||
Control | 0..* | ||||
Type | Attachment | ||||
Is Modifier | false | ||||
Summary | false | ||||
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. | ||||
Invariants | ele-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。 | ||||
Control | 0..* | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | Report, Test, Result, Results, Labs, Laboratory | ||||
Invariants | dom-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。 | ||||
Control | 0..1 | ||||
Type | id | ||||
Is Modifier | false | ||||
Summary | true | ||||
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 | ||||
Control | 0..1 | ||||
Type | Meta | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-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。 | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | true 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 Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-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)。 | ||||
Control | 0..1 | ||||
Binding | The 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。
| ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Example | <br/><b>Value</b>:zh-TW | ||||
Invariants | ele-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。 | ||||
Short | DiagnosticReport 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。 | ||||
Control | 0..1 | ||||
Type | Narrative | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | narrative, html, xhtml, display | ||||
Invariants | ele-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. | ||||
Short | Contained, 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. | ||||
Control | 0..* | ||||
Type | Resource | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | inline 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. | ||||
Short | Additional 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-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). | ||||
Short | Extensions 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them | ||||
Summary | false | ||||
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 Names | extensions, user content | ||||
Invariants | ele-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 | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 0..* | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | true | ||||
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 Names | ReportID, Filler ID, Placer ID | ||||
Invariants | ele-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。 | ||||
Control | 0..* | ||||
Type | Reference(TW Core CarePlan, ImmunizationRecommendation, TW Core MedicationRequest, NutritionOrder, TW Core ServiceRequest) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | 允許追蹤報告的授權,並追蹤提案/建議是否被採納。 | ||||
Alternate Names | Request | ||||
Invariants | ele-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 | ||||
Short | registered | partial | preliminary | final + | ||||
Control | 1..1 | ||||
Binding | The 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 | ||||
Type | code | ||||
Is Modifier | true 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 Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
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。 | ||||
Invariants | ele-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。 | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | Unless 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。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Alternate Names | Department, Sub-department, Service, Discipline | ||||
Invariants | ele-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. | ||||
Control | 1..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The 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。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Alternate Names | Type | ||||
Invariants | ele-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。 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
30. DiagnosticReport.code.extension | |||||
Definition | 擴充的資料項目 | ||||
Short | 擴充的資料項目 | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-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() ) | ||||
Slicing | This element introduces a set of slices on DiagnosticReport.code.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
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。 | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Requirements | 允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
Slicing | This element introduces a set of slices on DiagnosticReport.code.coding . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
34. DiagnosticReport.code.coding:LOINCObservationCode | |||||
Slice Name | LOINCObservationCode | ||||
Definition | 由專門術語系統(terminology system)所定義之代碼的參照 | ||||
Short | LOINC®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。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The 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。 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Requirements | 允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。 | ||||
Invariants | ele-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。 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
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。 | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-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() ) | ||||
Slicing | This element introduces a set of slices on DiagnosticReport.code.coding.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
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。 | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | 需要明確說明符號定義的來源 | ||||
Pattern Value | http://loinc.org | ||||
Invariants | ele-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。 | ||||
Note | This is a business version Id, not a resource version Id (see discussion) | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-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 | ||||
Control | 1..1 | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | 需要參照系統中的一個特定代碼 | ||||
Invariants | ele-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 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | 需要能為不了解此系統的讀者呈現可讀的代碼含義 | ||||
Invariants | ele-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。 | ||||
Control | 0..1 | ||||
Type | boolean | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
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。 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
50. DiagnosticReport.code.coding:TWLaboratoryCategory | |||||
Slice Name | TWLaboratoryCategory | ||||
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。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The 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。 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Requirements | 允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。 | ||||
Invariants | ele-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。 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
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。 | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-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() ) | ||||
Slicing | This element introduces a set of slices on DiagnosticReport.code.coding.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
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。 | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | 需要明確說明符號定義的來源 | ||||
Pattern Value | https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-service-payment-tw | ||||
Invariants | ele-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。 | ||||
Note | This is a business version Id, not a resource version Id (see discussion) | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-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 | ||||
Control | 1..1 | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | 需要參照系統中的一個特定代碼 | ||||
Invariants | ele-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 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | 需要能為不了解此系統的讀者呈現可讀的代碼含義 | ||||
Invariants | ele-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。 | ||||
Control | 0..1 | ||||
Type | boolean | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
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。 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
66. DiagnosticReport.code.coding:TW2021ICD10PCS | |||||
Slice Name | TW2021ICD10PCS | ||||
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。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The 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。 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Requirements | 允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。 | ||||
Invariants | ele-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。 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
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。 | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-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() ) | ||||
Slicing | This element introduces a set of slices on DiagnosticReport.code.coding.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
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。 | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | 需要明確說明符號定義的來源 | ||||
Pattern Value | https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-pcs-2021-tw | ||||
Invariants | ele-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。 | ||||
Note | This is a business version Id, not a resource version Id (see discussion) | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-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 | ||||
Control | 1..1 | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | 需要參照系統中的一個特定代碼 | ||||
Invariants | ele-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 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | 需要能為不了解此系統的讀者呈現可讀的代碼含義 | ||||
Invariants | ele-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。 | ||||
Control | 0..1 | ||||
Type | boolean | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
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。 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
82. DiagnosticReport.code.coding:TW2023ICD10PCS | |||||
Slice Name | TW2023ICD10PCS | ||||
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。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The 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。 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Requirements | 允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。 | ||||
Invariants | ele-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。 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
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。 | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-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() ) | ||||
Slicing | This element introduces a set of slices on DiagnosticReport.code.coding.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
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。 | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | 需要明確說明符號定義的來源 | ||||
Pattern Value | https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-pcs-2023-tw | ||||
Invariants | ele-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。 | ||||
Note | This is a business version Id, not a resource version Id (see discussion) | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-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 | ||||
Control | 1..1 | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | 需要參照系統中的一個特定代碼 | ||||
Invariants | ele-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 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | 需要能為不了解此系統的讀者呈現可讀的代碼含義 | ||||
Invariants | ele-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。 | ||||
Control | 0..1 | ||||
Type | boolean | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
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。 | ||||
Invariants | ele-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。 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
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。 | ||||
Invariants | ele-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 | ||||
Control | 1..1 | ||||
Type | Reference(TW Core Patient, Group, Device, TW Core Location) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Must Support Types | No must-support rules about the choice of types/profiles | ||||
Summary | true | ||||
Requirements | 必須(SHALL) 知道對象的背景 | ||||
Alternate Names | Patient | ||||
Invariants | ele-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)。 | ||||
Control | 0..1 | ||||
Type | Reference(TW Core Encounter) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | 將此服務請求連接就醫(Encounter)情境 | ||||
Alternate Names | Context | ||||
Invariants | ele-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。 | ||||
Control | 0..1 | ||||
Type | Choice of: dateTime, Period | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Must Support Types | dateTime | ||||
Summary | true | ||||
Requirements | 需要知道在病歷的什麼地方儲存檔案/呈現此報告 | ||||
Alternate Names | Observation time, Effective Time, Occurrence | ||||
Invariants | ele-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。 | ||||
Control | 0..1 | ||||
Type | instant | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | 臨床醫師需要確認報告的發布日期 | ||||
Alternate Names | Date published, Date Issued, Date Verified | ||||
Invariants | ele-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。 | ||||
Control | 0..* | ||||
Type | Reference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, TW Core CareTeam) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Must Support Types | No must-support rules about the choice of types/profiles | ||||
Summary | true | ||||
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 Names | Laboratory, Service, Practitioner, Department, Company, Authorized by, Director | ||||
Invariants | ele-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 | ||||
Control | 0..* | ||||
Type | Reference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, TW Core CareTeam) | ||||
Is Modifier | false | ||||
Summary | true | ||||
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 Names | Analyzed by, Reported by | ||||
Invariants | ele-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。 | ||||
Control | 0..* | ||||
Type | Reference(Specimen) | ||||
Is Modifier | false | ||||
Summary | false | ||||
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。 | ||||
Invariants | ele-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 | ||||
Control | 0..* | ||||
Type | Reference(TW Core Observation Laboratory Result) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
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 Names | Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer | ||||
Invariants | ele-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。 | ||||
Control | 0..* | ||||
Type | Reference(TW Core ImagingStudy) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-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 | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | true | ||||
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 Names | DICOM, Slides, Scans | ||||
Invariants | ele-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. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
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. | ||||
Short | Additional 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-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). | ||||
Short | Extensions 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
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 Names | extensions, user content, modifiers | ||||
Invariants | ele-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。 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
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 | ||||
Invariants | ele-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 | ||||
Control | 1..1 | ||||
Type | Reference(TW Core Media) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-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) | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | 需要能夠提供一個不會在基本結果資料中丟失結論 | ||||
Alternate Names | Report | ||||
Invariants | ele-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. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from SNOMEDCTClinicalFindings (extensible to http://hl7.org/fhir/ValueSet/clinical-findings ) | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-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。 | ||||
Control | 0..* | ||||
Type | Attachment | ||||
Is Modifier | false | ||||
Summary | false | ||||
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 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) |