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

臺灣核心實作指引(TW Core IG), published by 衛生福利部. This guide is not an authorized publication; it is the continuous build for version 0.3.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cctwFHIRterm/MOHW_TWCoreIG_Build/ and changes regularly. See the Directory of published versions

Resource Profile: TWCoreDocumentReference - Detailed Descriptions

Active as of 2024-11-07

Definitions for the DocumentReference-twcore resource profile.

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

0. DocumentReference
Definition

這是對任何目的文件的參照。它提供了有關文件的metadata,以便能夠找到並管理此文件。文件的範圍包括任何具有MIME類型的序列物件(seralized object),例如:以病人為中心的文件(CDA)、臨床註釋、掃描的紙張,以及非與病人有關的文件,像是政策文字表述。

Short文件的參照
Comments

通常,這用於除了由FHIR定義之外的文件。

2. DocumentReference.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DocumentReference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. DocumentReference.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DocumentReference Resource的metadata
6. DocumentReference.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. DocumentReference.language
Definition

編寫此resource的語言

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

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

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

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

Additional BindingsPurpose
AllLanguagesMax Binding
Example<br/><b>Value</b>:zh-TW
10. DocumentReference.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。

ShortDocumentReference 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. DocumentReference.masterIdentifier
Definition

這個文件的唯一識別碼是由提供該文件的來源所賦予的。這個識別碼僅適用於該文件的特定版本。這個獨特的識別碼也可能在其他情況下用於辨認這一版本的文件

Short主版本的識別碼
Comments

CDA 文件 Id extension及root

Must Supporttrue
Requirements

這個 Id 的結構和格式應與對應於 formatCode 屬性的規範一致。例如:對於 DICOM 標準文件,為64字元數字 UID;對於 HL7 CDA 格式,則為 CDA Document Id extension和 root 的序列化,格式為「oid^extension」,其中 OID 最多64位數字,Id 最多16位 UTF-8 字元。如果 OID 是不帶extension的編碼,則不應包含「^」字元。

14. DocumentReference.identifier
Definition

與文件相關的其他識別碼,包括不分版本的識別碼。

Short文件的其他的識別碼
NoteThis is a business identifier, not a resource identifier (see discussion)
16. DocumentReference.status
Definition

此文件參照的狀態

Comments

DocumentReference 物件的狀態,可能與 docStatus 資料項目無關,兩者可以是獨立設定。 此資料項目被標記為修飾用(modifier),因為狀態包含標記 resource 為當前無效的代碼。

BindingThe codes SHALL be taken from DocumentReferenceStatus
(required to http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1)

文件參照的狀態;應填入所綁定值集中的其中一個代碼。

Must Supporttrue
18. DocumentReference.docStatus
Definition

基礎文件的狀態

Comments

被參照的文件可能會處在不同的階段或狀態中,例如初稿、完稿等不同的生命週期階段。

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

基礎文件的狀態;應填入所綁定值集中的其中一個代碼。

20. DocumentReference.type
Definition

被參照文件的具體類型,例如是關於病人的病史和體檢報告、出院摘要、病程摘要等。這樣的類型通常與文件被創建和使用的目的是一致的。

Short文件的類型(如果可能,使用 LOINC 代碼)
Comments

關鍵metadata描述了文件的確切類型,有助於人們在查看文件清單時判斷該文件是否感興趣。

BindingUnless not suitable, these codes SHALL be taken from LOINC Code Document Type值集
(extensible to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-type-doc-code)

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

TypeCodeableConcept(TW CodeableConcept)
Must Supporttrue
22. DocumentReference.category
Definition

文件的一個分類標準,用於幫助對文件進行索引和查詢。這個分類可能直接基於或是由 DocumentReference.type 指定的代碼來確定。

Short文件的類別
Comments

關鍵metadata描述文件的大類或類型。這種分類是基於文件可能的用途或功能,將具有相似用途的文件劃分為同一組。在進行文件查詢時,這個分類作為一個主要的查詢條件。

BindingUnless not suitable, these codes SHALL be taken from LOINC Document Class值集
(extensible to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-document-classcodes)

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

TypeCodeableConcept(TW CodeableConcept)
Must Supporttrue
24. DocumentReference.subject
Definition

文件可能涉及的對象範圍。這意味著文件可能描述的是一個人(例如病人或健康照護服務提供者)、一個設備(比如某種醫療機構),或者是一組特定的對象,比如一群農場動物或者一批有著相同健康風險的病人。

Short文件描述的對象是誰/是什麼?
Control1..?
TypeReference(TW Core Patient, TW Core Practitioner, Group, Device)
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
26. DocumentReference.date
Definition

文件參照的創建時間是何時?

Short文件參照的創建時間是何時?
Comments

文件的參照或索引時間被用於來追蹤文件的歷史、組織不同的版本及需要時查詢特定文件。

Must Supporttrue
28. DocumentReference.author
Definition

識別誰負責將資訊添加到文件中

Short誰以及/或什麼創建了文件
Comments

未必是輸入資料的人(例如:打字員),也不必是提供資訊的人(例如:資訊提供者)。

TypeReference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, Device, TW Core Patient, TW Core RelatedPerson)
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
30. DocumentReference.authenticator
Definition

哪個人或機構認證這份文件是有效的

Short誰/什麼對文件進行了認證
Comments

代表在作者機構內,一位已經合法認證或證實文件的參與者。合法認證意味著一份文件已經被法律認證人手動或電子簽章。

TypeReference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization)
32. DocumentReference.custodian
Definition

負責文件持續維護和存取的機構或團體

Short維護此文件的機構
Comments

為了找到文件的最新版本或是報告問題等,需要知道哪個組織(可能是某個軟體系統、供應商或部門)負責。這與文件實際存儲的實體位置(如網路地址、硬碟或伺服器)是不同的。實體位置指的是文件存放的地方,這個位置可能被授權給其他組織來進行管理。簡單來說,就是指明負責文件更新和問題反饋的機構,和文件存放位置之間的區別。

TypeReference(TW Core Organization)
34. DocumentReference.relatesTo
Definition

此文件與已經存在的其他文件參照之間的關係

Short與其他文件的關係
Comments

這個資料項目被標記為修飾用(modifier),因為附加到其他文件上的文件本身是不完整的。

36. DocumentReference.relatesTo.code
Definition

此文件與另一文件的關係類型

Comments

如果此文件是對另一份文件進行附加,那麼不存取被參照的文件,此文件就無法被完全理解。

BindingThe codes SHALL be taken from DocumentRelationshipType
(required to http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1)

文件之間的關係類型;應填入所綁定值集中的其中一個代碼。

38. DocumentReference.relatesTo.target
Definition

存在此關係的目標文件

Short存在此關係的目標文件
TypeReference(TW Core DocumentReference)
40. DocumentReference.description
Definition

來源文件的人可讀描述

Short人可讀的描述。
Comments

文件的內容簡介,提供了一個關於文件主要內容的簡明扼要的總結。

Requirements

有助於人們判斷文件是否具有興趣價值

42. DocumentReference.securityLabel
Definition

在文件的參照資訊中,會使用一系列的安全標籤代碼來指明該文件的隱私和安全等級。其中,DocumentReference.meta.security 用來表示參照這份文件本身的安全標籤,也就是說明參照資訊的安全等級;而 DocumentReference.securityLabel 則展示了被參照文件在那一刻的安全標籤狀態,即原始文件的安全等級。簡單來說,就是有兩種標籤,一種用於標示參照的安全性,另一種用於顯示原文件的安全性。

Short文件的安全標籤(security-tags)
Comments

一種用於文件共享環境中的安全性和隱私標籤系統,即HL7醫療隱私和安全分類系統(HCS)。這套系統包括多種與文件保密性、敏感度、資料完整性和特定處理要求相關的標籤或代碼,這些代碼有的是通用的,有的則可能是特定於某一機構或項目的。雖然這套系統被推薦使用於如XDS Affinity Domain這樣的政策領域中,但具體是否採用,以及如何採用,則取決於該領域的管理政策和規範。簡言之,這是一套幫助確定文件如何被標記和處理的標籤系統,但使用與否由各自的政策領域決定。

BindingUnless not suitable, these codes SHALL be taken from All Security Labels
(extensible to http://hl7.org/fhir/ValueSet/security-labels)

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

TypeCodeableConcept(TW CodeableConcept)
44. DocumentReference.content
Definition

參照的文件和格式。可能存在多個content資料項目,每個資料項目都有不同的格式。

Short被參照的文件
Must Supporttrue
46. DocumentReference.content.attachment
Definition

文件或文件的URL以及證明內容具有完整性的關鍵metadata

Short存取文件的位置
48. DocumentReference.content.format
Definition

這個識別碼用來表明文件符合的編碼方式、結構和模板,這些特性是除了在 mimeType(文件類型)裡已指明的基本格式之外的部分。

Short文件的格式/內容規則。
Comments

請注意,雖然 IHE 通常為不同格式類型發布統一資源名稱( URN),但並非所有文件都能透過 統一資源識別碼(URI) 來識別。

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

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。

50. DocumentReference.context
Definition

文件所涉及的臨床情境或背景

Short文件的臨床背景
Comments

這些值主要用於幫助查詢感興趣/相關的文件而添加的

52. DocumentReference.context.encounter
Definition

描述文件內容所關聯的臨床就醫事件或類型

Short文件內容的臨床背景
TypeReference(TW Core Encounter, EpisodeOfCare)
54. DocumentReference.context.event
Definition

這個代碼清單代表了正在記錄的主要臨床行為,例如:結腸鏡檢查或闌尾切除手術。在某些情況下,事件已經隱含在類型代碼中,例如在「病史和體檢報告」中,正在記錄的必然是「病史和體檢」行為。

Short正在記錄的主要臨床行為
Comments

事件可以進一步專注於類型中所隱含的行為,例如當它僅為「處置報告」,而該處置是「結腸鏡檢查」。如果包括一個或多個事件代碼,則它們不應與class或type資料項目中的值相衝突,因為這樣的衝突會導致情況變得模糊不清。

BindingFor example codes, see v3 Code System ActCode
(example to http://terminology.hl7.org/ValueSet/v3-ActCode)

可參考所綁定值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。

TypeCodeableConcept(TW CodeableConcept)
56. DocumentReference.context.period
Definition

文件描述的是提供服務的時間範圍

Short被記錄的服務時間
58. DocumentReference.context.facilityType
Definition

病人接受治療的機構類型

Short病人接受治療的機構類型
BindingFor example codes, see FacilityTypeCodeValueSet
(example to http://hl7.org/fhir/ValueSet/c80-facilitycodes)

可參考所綁定值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。

60. DocumentReference.context.practiceSetting
Definition

此屬性可能提供有關創建內容的實務環境細節,通常反映了臨床專業。

Short內容創建的額外細節(例如:臨床專業)
Comments

此資料項目應基於一個粗略的專業實務分類系統,建議使用實務環境(Practice Setting)的分類系統,例如:LOINC中的主題領域(Subject Matter Domain)所描述的。

BindingFor example codes, see PracticeSettingCodeValueSet
(example to http://hl7.org/fhir/ValueSet/c80-practice-codes)

可參考所綁定值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。

TypeCodeableConcept(TW CodeableConcept)
Requirements

這是健康照護服務提供者(provider)經常依賴的重要metadata之一,他們通常會用來快速排序和/或篩選以找到特定的內容。

62. DocumentReference.context.sourcePatientInfo
Definition

文件發佈時已知的病人資訊。可以是對特定版本的參照,也可以是包含在文件中的資訊。

Short來源的病人人口統計資料
TypeReference(TW Core Patient)
64. DocumentReference.context.related
Definition

與DocumentReference相關聯的相關識別碼或resources

Short相關的識別碼或resources
Comments

可能是導致創建 DocumentReference 或參照文件的識別碼或resources

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

0. DocumentReference
Definition

這是對任何目的文件的參照。它提供了有關文件的metadata,以便能夠找到並管理此文件。文件的範圍包括任何具有MIME類型的序列物件(seralized object),例如:以病人為中心的文件(CDA)、臨床註釋、掃描的紙張,以及非與病人有關的文件,像是政策文字表述。


A reference to a document of any kind for any purpose. Provides metadata about the document so that the document can be discovered and managed. The scope of a document is any seralized object with a mime-type, so includes formal patient centric documents (CDA), cliical notes, scanned paper, and non-patient specific documents like policy text.

Short文件的參照A reference to a document
Comments

通常,這用於除了由FHIR定義之外的文件。


Usually, this is used for documents other than those defined by FHIR.

Control0..*
Is Modifierfalse
Summaryfalse
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. DocumentReference.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DocumentReference紀錄,通常又稱為邏輯性ID。Logical id of this artifact
Comments

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


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

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

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


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

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

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


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

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

編寫此resource的語言


The base language in which the resource is written.

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

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


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

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

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


A human language.

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

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

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


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

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

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

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

ShortExtensions that cannot be ignored
Comments

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

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

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

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

這個文件的唯一識別碼是由提供該文件的來源所賦予的。這個識別碼僅適用於該文件的特定版本。這個獨特的識別碼也可能在其他情況下用於辨認這一版本的文件


Document identifier as assigned by the source of the document. This identifier is specific to this version of the document. This unique identifier may be used elsewhere to identify this version of the document.

Short主版本的識別碼Master Version Specific Identifier
Comments

CDA 文件 Id extension及root


CDA Document Id extension and root.

Control0..1
TypeIdentifier
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

這個 Id 的結構和格式應與對應於 formatCode 屬性的規範一致。例如:對於 DICOM 標準文件,為64字元數字 UID;對於 HL7 CDA 格式,則為 CDA Document Id extension和 root 的序列化,格式為「oid^extension」,其中 OID 最多64位數字,Id 最多16位 UTF-8 字元。如果 OID 是不帶extension的編碼,則不應包含「^」字元。


The structure and format of this Id shall be consistent with the specification corresponding to the formatCode attribute. (e.g. for a DICOM standard document a 64-character numeric UID, for an HL7 CDA format a serialization of the CDA Document Id extension and root in the form "oid^extension", where OID is a 64 digits max, and the Id is a 16 UTF-8 char max. If the OID is coded without the extension then the '^' character shall not be included.).

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

與文件相關的其他識別碼,包括不分版本的識別碼。


Other identifiers associated with the document, including version independent identifiers.

Short文件的其他的識別碼Other identifiers for the document
NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
18. DocumentReference.status
Definition

此文件參照的狀態


The status of this document reference.

Shortcurrent | superseded | entered-in-error
Comments

DocumentReference 物件的狀態,可能與 docStatus 資料項目無關,兩者可以是獨立設定。 此資料項目被標記為修飾用(modifier),因為狀態包含標記 resource 為當前無效的代碼。


This is the status of the DocumentReference object, which might be independent from the docStatus element.

This element is labeled as a modifier because the status contains the codes that mark the document or reference as not currently valid.

Control1..1
BindingThe codes SHALL be taken from DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
(required to http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1)

文件參照的狀態;應填入所綁定值集中的其中一個代碼。


The status of the document reference.

Typecode
Is Modifiertrue because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. DocumentReference.docStatus
Definition

基礎文件的狀態


The status of the underlying document.

Shortpreliminary | final | amended | entered-in-error
Comments

被參照的文件可能會處在不同的階段或狀態中,例如初稿、完稿等不同的生命週期階段。


The document that is pointed to might be in various lifecycle states.

Control0..1
BindingThe codes SHALL be taken from CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1
(required to http://hl7.org/fhir/ValueSet/composition-status|4.0.1)

基礎文件的狀態;應填入所綁定值集中的其中一個代碼。


Status of the underlying document.

Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. DocumentReference.type
Definition

被參照文件的具體類型,例如是關於病人的病史和體檢報告、出院摘要、病程摘要等。這樣的類型通常與文件被創建和使用的目的是一致的。


Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced.

Short文件的類型(如果可能,使用 LOINC 代碼)Kind of document (LOINC if possible)
Comments

關鍵metadata描述了文件的確切類型,有助於人們在查看文件清單時判斷該文件是否感興趣。


Key metadata element describing the document that describes he exact type of document. Helps humans to assess whether the document is of interest when viewing a list of documents.

Control0..1
This element is affected by the following invariants: ele-1
BindingUnless not suitable, these codes SHALL be taken from The codes SHOULD be taken from LOINC Code Document Type值集http://hl7.org/fhir/ValueSet/c80-doc-typecodes
(extensible to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-type-doc-code)

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


Precise type of clinical document.

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

文件的一個分類標準,用於幫助對文件進行索引和查詢。這個分類可能直接基於或是由 DocumentReference.type 指定的代碼來確定。


A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.

Short文件的類別Categorization of document
Comments

關鍵metadata描述文件的大類或類型。這種分類是基於文件可能的用途或功能,將具有相似用途的文件劃分為同一組。在進行文件查詢時,這個分類作為一個主要的查詢條件。


Key metadata element describing the the category or classification of the document. This is a broader perspective that groups similar documents based on how they would be used. This is a primary key used in searching.

Control0..*
This element is affected by the following invariants: ele-1
BindingUnless not suitable, these codes SHALL be taken from For example codes, see LOINC Document Class值集http://hl7.org/fhir/ValueSet/document-classcodes
(extensible to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-document-classcodes)

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


High-level kind of a clinical document at a macro level.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Alternate Namesclaxs
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. DocumentReference.subject
Definition

文件可能涉及的對象範圍。這意味著文件可能描述的是一個人(例如病人或健康照護服務提供者)、一個設備(比如某種醫療機構),或者是一組特定的對象,比如一群農場動物或者一批有著相同健康風險的病人。


Who or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of farm animals, or a set of patients that share a common exposure).

Short文件描述的對象是誰/是什麼?Who/what is the subject of the document
Control10..1
TypeReference(TW Core Patient, TW Core Practitioner, Group, Device, Patient, Practitioner)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. DocumentReference.date
Definition

文件參照的創建時間是何時?


When the document reference was created.

Short文件參照的創建時間是何時?When this document reference was created
Comments

文件的參照或索引時間被用於來追蹤文件的歷史、組織不同的版本及需要時查詢特定文件。


Referencing/indexing time is used for tracking, organizing versions and searching.

Control0..1
Typeinstant
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Alternate Namesindexed
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. DocumentReference.author
Definition

識別誰負責將資訊添加到文件中


Identifies who is responsible for adding the information to the document.

Short誰以及/或什麼創建了文件Who and/or what authored the document
Comments

未必是輸入資料的人(例如:打字員),也不必是提供資訊的人(例如:資訊提供者)。


Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant).

Control0..*
TypeReference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, Device, TW Core Patient, TW Core RelatedPerson, Practitioner, PractitionerRole, Organization, Patient, RelatedPerson)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. DocumentReference.authenticator
Definition

哪個人或機構認證這份文件是有效的


Which person or organization authenticates that this document is valid.

Short誰/什麼對文件進行了認證Who/what authenticated the document
Comments

代表在作者機構內,一位已經合法認證或證實文件的參與者。合法認證意味著一份文件已經被法律認證人手動或電子簽章。


Represents a participant within the author institution who has legally authenticated or attested the document. Legal authentication implies that a document has been signed manually or electronically by the legal Authenticator.

Control0..1
TypeReference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, Practitioner, PractitionerRole, Organization)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. DocumentReference.custodian
Definition

負責文件持續維護和存取的機構或團體


Identifies the organization or group who is responsible for ongoing maintenance of and access to the document.

Short維護此文件的機構Organization which maintains the document
Comments

為了找到文件的最新版本或是報告問題等,需要知道哪個組織(可能是某個軟體系統、供應商或部門)負責。這與文件實際存儲的實體位置(如網路地址、硬碟或伺服器)是不同的。實體位置指的是文件存放的地方,這個位置可能被授權給其他組織來進行管理。簡單來說,就是指明負責文件更新和問題反饋的機構,和文件存放位置之間的區別。


Identifies the logical organization (software system, vendor, or department) to go to find the current version, where to report issues, etc. This is different from the physical location (URL, disk drive, or server) of the document, which is the technical location of the document, which host may be delegated to the management of some other organization.

Control0..1
TypeReference(TW Core Organization, Organization)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. DocumentReference.relatesTo
Definition

此文件與已經存在的其他文件參照之間的關係


Relationships that this document has with other document references that already exist.

Short與其他文件的關係Relationships to other documents
Comments

這個資料項目被標記為修飾用(modifier),因為附加到其他文件上的文件本身是不完整的。


This element is labeled as a modifier because documents that append to other documents are incomplete on their own.

Control0..*
TypeBackboneElement
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
38. DocumentReference.relatesTo.modifierExtension
Definition

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

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

ShortExtensions that cannot be ignored even if unrecognized
Comments

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

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

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

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

此文件與另一文件的關係類型


The type of relationship that this document has with anther document.

Shortreplaces | transforms | signs | appends
Comments

如果此文件是對另一份文件進行附加,那麼不存取被參照的文件,此文件就無法被完全理解。


If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.

Control1..1
BindingThe codes SHALL be taken from DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
(required to http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1)

文件之間的關係類型;應填入所綁定值集中的其中一個代碼。


The type of relationship between documents.

Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
42. DocumentReference.relatesTo.target
Definition

存在此關係的目標文件


The target document of this relationship.

Short存在此關係的目標文件Target of the relationship
Control1..1
TypeReference(TW Core DocumentReference, DocumentReference)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
44. DocumentReference.description
Definition

來源文件的人可讀描述


Human-readable description of the source document.

Short人可讀的描述。Human-readable description
Comments

文件的內容簡介,提供了一個關於文件主要內容的簡明扼要的總結。


What the document is about, a terse summary of the document.

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

有助於人們判斷文件是否具有興趣價值


Helps humans to assess whether the document is of interest.

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

在文件的參照資訊中,會使用一系列的安全標籤代碼來指明該文件的隱私和安全等級。其中,DocumentReference.meta.security 用來表示參照這份文件本身的安全標籤,也就是說明參照資訊的安全等級;而 DocumentReference.securityLabel 則展示了被參照文件在那一刻的安全標籤狀態,即原始文件的安全等級。簡單來說,就是有兩種標籤,一種用於標示參照的安全性,另一種用於顯示原文件的安全性。


A set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security contains the security labels of the "reference" to the document, while DocumentReference.securityLabel contains a snapshot of the security labels on the document the reference refers to.

Short文件的安全標籤(security-tags)Document security-tags
Comments

一種用於文件共享環境中的安全性和隱私標籤系統,即HL7醫療隱私和安全分類系統(HCS)。這套系統包括多種與文件保密性、敏感度、資料完整性和特定處理要求相關的標籤或代碼,這些代碼有的是通用的,有的則可能是特定於某一機構或項目的。雖然這套系統被推薦使用於如XDS Affinity Domain這樣的政策領域中,但具體是否採用,以及如何採用,則取決於該領域的管理政策和規範。簡言之,這是一套幫助確定文件如何被標記和處理的標籤系統,但使用與否由各自的政策領域決定。


The confidentiality codes can carry multiple vocabulary items. HL7 has developed an understanding of security and privacy tags that might be desirable in a Document Sharing environment, called HL7 Healthcare Privacy and Security Classification System (HCS). The following specification is recommended but not mandated, as the vocabulary bindings are an administrative domain responsibility. The use of this method is up to the policy domain such as the XDS Affinity Domain or other Trust Domain where all parties including sender and recipients are trusted to appropriately tag and enforce.

In the HL7 Healthcare Privacy and Security Classification (HCS) there are code systems specific to Confidentiality, Sensitivity, Integrity, and Handling Caveats. Some values would come from a local vocabulary as they are related to workflow roles and special projects.

Control0..*
This element is affected by the following invariants: ele-1
BindingUnless not suitable, these codes SHALL be taken from All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels
(extensible to http://hl7.org/fhir/ValueSet/security-labels)

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


Security Labels from the Healthcare Privacy and Security Classification System.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Requirements

Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.

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

參照的文件和格式。可能存在多個content資料項目,每個資料項目都有不同的格式。


The document and format referenced. There may be multiple content element repetitions, each with a different format.

Short被參照的文件Document referenced
Control1..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. DocumentReference.content.modifierExtension
Definition

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

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

ShortExtensions that cannot be ignored even if unrecognized
Comments

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

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

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

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

文件或文件的URL以及證明內容具有完整性的關鍵metadata


The document or URL of the document along with critical metadata to prove content has integrity.

Short存取文件的位置Where to access the document
Control1..1
TypeAttachment
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
54. DocumentReference.content.format
Definition

這個識別碼用來表明文件符合的編碼方式、結構和模板,這些特性是除了在 mimeType(文件類型)裡已指明的基本格式之外的部分。


An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

Short文件的格式/內容規則。Format/content rules for the document
Comments

請注意,雖然 IHE 通常為不同格式類型發布統一資源名稱( URN),但並非所有文件都能透過 統一資源識別碼(URI) 來識別。


Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI.

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

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。


Document Format Codes.

TypeCoding
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
56. DocumentReference.context
Definition

文件所涉及的臨床情境或背景


The clinical context in which the document was prepared.

Short文件的臨床背景Clinical context of document
Comments

這些值主要用於幫助查詢感興趣/相關的文件而添加的


These values are primarily added to help with searching for interesting/relevant documents.

Control0..1
TypeBackboneElement
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
58. DocumentReference.context.modifierExtension
Definition

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

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

ShortExtensions that cannot be ignored even if unrecognized
Comments

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

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

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

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

描述文件內容所關聯的臨床就醫事件或類型


Describes the clinical encounter or type of care that the document content is associated with.

Short文件內容的臨床背景Context of the document content
Control0..*
TypeReference(TW Core Encounter, EpisodeOfCare, Encounter)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
62. DocumentReference.context.event
Definition

這個代碼清單代表了正在記錄的主要臨床行為,例如:結腸鏡檢查或闌尾切除手術。在某些情況下,事件已經隱含在類型代碼中,例如在「病史和體檢報告」中,正在記錄的必然是「病史和體檢」行為。


This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the type Code, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act.

Short正在記錄的主要臨床行為Main clinical acts documented
Comments

事件可以進一步專注於類型中所隱含的行為,例如當它僅為「處置報告」,而該處置是「結腸鏡檢查」。如果包括一個或多個事件代碼,則它們不應與class或type資料項目中的值相衝突,因為這樣的衝突會導致情況變得模糊不清。


An event can further specialize the act inherent in the type, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more event codes are included, they shall not conflict with the values inherent in the class or type elements as such a conflict would create an ambiguous situation.

Control0..*
This element is affected by the following invariants: ele-1
BindingFor example codes, see v3 Code System ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode
(example to http://terminology.hl7.org/ValueSet/v3-ActCode)

可參考所綁定值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。


This list of codes represents the main clinical acts being documented.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
64. DocumentReference.context.period
Definition

文件描述的是提供服務的時間範圍


The time period over which the service that is described by the document was provided.

Short被記錄的服務時間Time of service that is being documented
Control0..1
TypePeriod
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
66. DocumentReference.context.facilityType
Definition

病人接受治療的機構類型


The kind of facility where the patient was seen.

Short病人接受治療的機構類型Kind of facility where patient was seen
Control0..1
BindingFor example codes, see FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodes
(example to http://hl7.org/fhir/ValueSet/c80-facilitycodes)

可參考所綁定值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。


XDS Facility Type.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
68. DocumentReference.context.practiceSetting
Definition

此屬性可能提供有關創建內容的實務環境細節,通常反映了臨床專業。


This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty.

Short內容創建的額外細節(例如:臨床專業)Additional details about where the content was created (e.g. clinical specialty)
Comments

此資料項目應基於一個粗略的專業實務分類系統,建議使用實務環境(Practice Setting)的分類系統,例如:LOINC中的主題領域(Subject Matter Domain)所描述的。


This element should be based on a coarse classification system for the class of specialty practice. Recommend the use of the classification system for Practice Setting, such as that described by the Subject Matter Domain in LOINC.

Control0..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codes
(example to http://hl7.org/fhir/ValueSet/c80-practice-codes)

可參考所綁定值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。


Additional details about where the content was created (e.g. clinical specialty).

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Requirements

這是健康照護服務提供者(provider)經常依賴的重要metadata之一,他們通常會用來快速排序和/或篩選以找到特定的內容。


This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.

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

文件發佈時已知的病人資訊。可以是對特定版本的參照,也可以是包含在文件中的資訊。


The Patient Information as known when the document was published. May be a reference to a version specific, or contained.

Short來源的病人人口統計資料Patient demographics from source
Control0..1
TypeReference(TW Core Patient, Patient)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
72. DocumentReference.context.related
Definition

與DocumentReference相關聯的相關識別碼或resources


Related identifiers or resources associated with the DocumentReference.

Short相關的識別碼或resourcesRelated identifiers or resources
Comments

可能是導致創建 DocumentReference 或參照文件的識別碼或resources


May be identifiers or resources that caused the DocumentReference or referenced Document to be created.

Control0..*
TypeReference(Resource)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

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

0. DocumentReference
Definition

這是對任何目的文件的參照。它提供了有關文件的metadata,以便能夠找到並管理此文件。文件的範圍包括任何具有MIME類型的序列物件(seralized object),例如:以病人為中心的文件(CDA)、臨床註釋、掃描的紙張,以及非與病人有關的文件,像是政策文字表述。

Short文件的參照
Comments

通常,這用於除了由FHIR定義之外的文件。

Control0..*
Is Modifierfalse
Summaryfalse
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. DocumentReference.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DocumentReference紀錄,通常又稱為邏輯性ID。
Comments

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

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

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

Short創建此內容所依據的一組規則
Comments

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

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

編寫此resource的語言

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

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

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

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

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

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

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

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

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

ShortContained, inline Resources
Comments

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

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

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

ShortAdditional content defined by implementations
Comments

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

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

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

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

ShortExtensions that cannot be ignored
Comments

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

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

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

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

這個文件的唯一識別碼是由提供該文件的來源所賦予的。這個識別碼僅適用於該文件的特定版本。這個獨特的識別碼也可能在其他情況下用於辨認這一版本的文件

Short主版本的識別碼
Comments

CDA 文件 Id extension及root

Control0..1
TypeIdentifier
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

這個 Id 的結構和格式應與對應於 formatCode 屬性的規範一致。例如:對於 DICOM 標準文件,為64字元數字 UID;對於 HL7 CDA 格式,則為 CDA Document Id extension和 root 的序列化,格式為「oid^extension」,其中 OID 最多64位數字,Id 最多16位 UTF-8 字元。如果 OID 是不帶extension的編碼,則不應包含「^」字元。

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

與文件相關的其他識別碼,包括不分版本的識別碼。

Short文件的其他的識別碼
NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. DocumentReference.status
Definition

此文件參照的狀態

Shortcurrent | superseded | entered-in-error
Comments

DocumentReference 物件的狀態,可能與 docStatus 資料項目無關,兩者可以是獨立設定。 此資料項目被標記為修飾用(modifier),因為狀態包含標記 resource 為當前無效的代碼。

Control1..1
BindingThe codes SHALL be taken from DocumentReferenceStatus
(required to http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1)

文件參照的狀態;應填入所綁定值集中的其中一個代碼。

Typecode
Is Modifiertrue because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. DocumentReference.docStatus
Definition

基礎文件的狀態

Shortpreliminary | final | amended | entered-in-error
Comments

被參照的文件可能會處在不同的階段或狀態中,例如初稿、完稿等不同的生命週期階段。

Control0..1
BindingThe codes SHALL be taken from CompositionStatus
(required to http://hl7.org/fhir/ValueSet/composition-status|4.0.1)

基礎文件的狀態;應填入所綁定值集中的其中一個代碼。

Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. DocumentReference.type
Definition

被參照文件的具體類型,例如是關於病人的病史和體檢報告、出院摘要、病程摘要等。這樣的類型通常與文件被創建和使用的目的是一致的。

Short文件的類型(如果可能,使用 LOINC 代碼)
Comments

關鍵metadata描述了文件的確切類型,有助於人們在查看文件清單時判斷該文件是否感興趣。

Control0..1
This element is affected by the following invariants: ele-1
BindingUnless not suitable, these codes SHALL be taken from LOINC Code Document Type值集
(extensible to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-type-doc-code)

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

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

文件的一個分類標準,用於幫助對文件進行索引和查詢。這個分類可能直接基於或是由 DocumentReference.type 指定的代碼來確定。

Short文件的類別
Comments

關鍵metadata描述文件的大類或類型。這種分類是基於文件可能的用途或功能,將具有相似用途的文件劃分為同一組。在進行文件查詢時,這個分類作為一個主要的查詢條件。

Control0..*
This element is affected by the following invariants: ele-1
BindingUnless not suitable, these codes SHALL be taken from LOINC Document Class值集
(extensible to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-document-classcodes)

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

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Alternate Namesclaxs
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. DocumentReference.subject
Definition

文件可能涉及的對象範圍。這意味著文件可能描述的是一個人(例如病人或健康照護服務提供者)、一個設備(比如某種醫療機構),或者是一組特定的對象,比如一群農場動物或者一批有著相同健康風險的病人。

Short文件描述的對象是誰/是什麼?
Control1..1
TypeReference(TW Core Patient, TW Core Practitioner, Group, Device)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. DocumentReference.date
Definition

文件參照的創建時間是何時?

Short文件參照的創建時間是何時?
Comments

文件的參照或索引時間被用於來追蹤文件的歷史、組織不同的版本及需要時查詢特定文件。

Control0..1
Typeinstant
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Alternate Namesindexed
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. DocumentReference.author
Definition

識別誰負責將資訊添加到文件中

Short誰以及/或什麼創建了文件
Comments

未必是輸入資料的人(例如:打字員),也不必是提供資訊的人(例如:資訊提供者)。

Control0..*
TypeReference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, Device, TW Core Patient, TW Core RelatedPerson)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. DocumentReference.authenticator
Definition

哪個人或機構認證這份文件是有效的

Short誰/什麼對文件進行了認證
Comments

代表在作者機構內,一位已經合法認證或證實文件的參與者。合法認證意味著一份文件已經被法律認證人手動或電子簽章。

Control0..1
TypeReference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
38. DocumentReference.custodian
Definition

負責文件持續維護和存取的機構或團體

Short維護此文件的機構
Comments

為了找到文件的最新版本或是報告問題等,需要知道哪個組織(可能是某個軟體系統、供應商或部門)負責。這與文件實際存儲的實體位置(如網路地址、硬碟或伺服器)是不同的。實體位置指的是文件存放的地方,這個位置可能被授權給其他組織來進行管理。簡單來說,就是指明負責文件更新和問題反饋的機構,和文件存放位置之間的區別。

Control0..1
TypeReference(TW Core Organization)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
40. DocumentReference.relatesTo
Definition

此文件與已經存在的其他文件參照之間的關係

Short與其他文件的關係
Comments

這個資料項目被標記為修飾用(modifier),因為附加到其他文件上的文件本身是不完整的。

Control0..*
TypeBackboneElement
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
42. DocumentReference.relatesTo.id
Definition

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

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

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

ShortAdditional content defined by implementations
Comments

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

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

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

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

ShortExtensions that cannot be ignored even if unrecognized
Comments

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

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

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

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

此文件與另一文件的關係類型

Shortreplaces | transforms | signs | appends
Comments

如果此文件是對另一份文件進行附加,那麼不存取被參照的文件,此文件就無法被完全理解。

Control1..1
BindingThe codes SHALL be taken from DocumentRelationshipType
(required to http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1)

文件之間的關係類型;應填入所綁定值集中的其中一個代碼。

Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. DocumentReference.relatesTo.target
Definition

存在此關係的目標文件

Short存在此關係的目標文件
Control1..1
TypeReference(TW Core DocumentReference)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
52. DocumentReference.description
Definition

來源文件的人可讀描述

Short人可讀的描述。
Comments

文件的內容簡介,提供了一個關於文件主要內容的簡明扼要的總結。

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

有助於人們判斷文件是否具有興趣價值

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

在文件的參照資訊中,會使用一系列的安全標籤代碼來指明該文件的隱私和安全等級。其中,DocumentReference.meta.security 用來表示參照這份文件本身的安全標籤,也就是說明參照資訊的安全等級;而 DocumentReference.securityLabel 則展示了被參照文件在那一刻的安全標籤狀態,即原始文件的安全等級。簡單來說,就是有兩種標籤,一種用於標示參照的安全性,另一種用於顯示原文件的安全性。

Short文件的安全標籤(security-tags)
Comments

一種用於文件共享環境中的安全性和隱私標籤系統,即HL7醫療隱私和安全分類系統(HCS)。這套系統包括多種與文件保密性、敏感度、資料完整性和特定處理要求相關的標籤或代碼,這些代碼有的是通用的,有的則可能是特定於某一機構或項目的。雖然這套系統被推薦使用於如XDS Affinity Domain這樣的政策領域中,但具體是否採用,以及如何採用,則取決於該領域的管理政策和規範。簡言之,這是一套幫助確定文件如何被標記和處理的標籤系統,但使用與否由各自的政策領域決定。

Control0..*
This element is affected by the following invariants: ele-1
BindingUnless not suitable, these codes SHALL be taken from All Security Labels
(extensible to http://hl7.org/fhir/ValueSet/security-labels)

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

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Requirements

Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.

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

參照的文件和格式。可能存在多個content資料項目,每個資料項目都有不同的格式。

Short被參照的文件
Control1..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
58. DocumentReference.content.id
Definition

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

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

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

ShortAdditional content defined by implementations
Comments

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

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

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

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

ShortExtensions that cannot be ignored even if unrecognized
Comments

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

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

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

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

文件或文件的URL以及證明內容具有完整性的關鍵metadata

Short存取文件的位置
Control1..1
TypeAttachment
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
66. DocumentReference.content.format
Definition

這個識別碼用來表明文件符合的編碼方式、結構和模板,這些特性是除了在 mimeType(文件類型)裡已指明的基本格式之外的部分。

Short文件的格式/內容規則。
Comments

請注意,雖然 IHE 通常為不同格式類型發布統一資源名稱( URN),但並非所有文件都能透過 統一資源識別碼(URI) 來識別。

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

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。

TypeCoding
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
68. DocumentReference.context
Definition

文件所涉及的臨床情境或背景

Short文件的臨床背景
Comments

這些值主要用於幫助查詢感興趣/相關的文件而添加的

Control0..1
TypeBackboneElement
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
70. DocumentReference.context.id
Definition

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

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

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

ShortAdditional content defined by implementations
Comments

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

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

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

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

ShortExtensions that cannot be ignored even if unrecognized
Comments

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

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

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

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

描述文件內容所關聯的臨床就醫事件或類型

Short文件內容的臨床背景
Control0..*
TypeReference(TW Core Encounter, EpisodeOfCare)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
78. DocumentReference.context.event
Definition

這個代碼清單代表了正在記錄的主要臨床行為,例如:結腸鏡檢查或闌尾切除手術。在某些情況下,事件已經隱含在類型代碼中,例如在「病史和體檢報告」中,正在記錄的必然是「病史和體檢」行為。

Short正在記錄的主要臨床行為
Comments

事件可以進一步專注於類型中所隱含的行為,例如當它僅為「處置報告」,而該處置是「結腸鏡檢查」。如果包括一個或多個事件代碼,則它們不應與class或type資料項目中的值相衝突,因為這樣的衝突會導致情況變得模糊不清。

Control0..*
This element is affected by the following invariants: ele-1
BindingFor example codes, see v3 Code System ActCode
(example to http://terminology.hl7.org/ValueSet/v3-ActCode)

可參考所綁定值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
80. DocumentReference.context.period
Definition

文件描述的是提供服務的時間範圍

Short被記錄的服務時間
Control0..1
TypePeriod
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
82. DocumentReference.context.facilityType
Definition

病人接受治療的機構類型

Short病人接受治療的機構類型
Control0..1
BindingFor example codes, see FacilityTypeCodeValueSet
(example to http://hl7.org/fhir/ValueSet/c80-facilitycodes)

可參考所綁定值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
84. DocumentReference.context.practiceSetting
Definition

此屬性可能提供有關創建內容的實務環境細節,通常反映了臨床專業。

Short內容創建的額外細節(例如:臨床專業)
Comments

此資料項目應基於一個粗略的專業實務分類系統,建議使用實務環境(Practice Setting)的分類系統,例如:LOINC中的主題領域(Subject Matter Domain)所描述的。

Control0..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see PracticeSettingCodeValueSet
(example to http://hl7.org/fhir/ValueSet/c80-practice-codes)

可參考所綁定值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Requirements

這是健康照護服務提供者(provider)經常依賴的重要metadata之一,他們通常會用來快速排序和/或篩選以找到特定的內容。

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

文件發佈時已知的病人資訊。可以是對特定版本的參照,也可以是包含在文件中的資訊。

Short來源的病人人口統計資料
Control0..1
TypeReference(TW Core Patient)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
88. DocumentReference.context.related
Definition

與DocumentReference相關聯的相關識別碼或resources

Short相關的識別碼或resources
Comments

可能是導致創建 DocumentReference 或參照文件的識別碼或resources

Control0..*
TypeReference(Resource)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))