臺灣核心實作指引(TW Core IG)
0.3.2 - Ci-Build Trial Use
臺灣核心實作指引(TW Core IG)
0.3.2 - Ci-Build Trial Use
臺灣核心實作指引(TW Core IG), published by 衛生福利部. This guide is not an authorized publication; it is the continuous build for version 0.3.2 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cctwFHIRterm/MOHW_TWCoreIG_Build/ and changes regularly. See the Directory of published versions
| Official URL: https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Observation-clinical-result-twcore | Version: 0.3.2 | |||
| Active as of 2024-12-20 | Computable Name: TWCoreObservationClinicalResult | |||
此臺灣核心-臨床檢驗檢查（TW Core Observation Clinical Result） Profile說明本IG如何進一步定義FHIR的Observation Resource以呈現臨床檢驗檢查資料。
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Observation
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
  Observation |
C | 0..* | Observation | 檢驗檢查，測量及簡單的判定。 tw-core-4: If there is no component or hasMember element then either a value[x] or a data absent reason must be present. | ||||
  id |
0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的Observation紀錄，通常又稱為邏輯性ID。 | |||||
| meta |
0..1 | Meta | 此Observation Resource的metadata | |||||
| implicitRules |
0..1 | uri | 創建此內容所依據的一組規則 | |||||
| language |
0..1 | code | 用以表述Observation Resource內容的語言。 Binding: CommonLanguages (preferred): 人類語言；鼓勵使用CommonLanguages代碼表中的代碼，但不強制一定要使用此代碼表，你也可使用其他代碼表的代碼或單純以文字表示。
Example Value: zh-TW | |||||
| text |
0..1 | Narrative | Observation Resource之內容摘要以供人閱讀 | |||||
| identifier |
0..* | Identifier | 檢驗檢查的識別碼，通常為業務目的所使用的識別碼，例如：檢驗序號或單號。 | |||||
 basedOn |
0..* | Reference(TW Core CarePlan | DeviceRequest | ImmunizationRecommendation | TW Core MedicationRequest | NutritionOrder | TW Core ServiceRequest) | 依據的照護計畫／提議／醫令 | |||||
| partOf |
0..* | Reference(MedicationAdministration | TW Core MedicationDispense | TW Core MedicationStatement | TW Core Procedure | TW Core Immunization | TW Core ImagingStudy) | 此檢驗檢查是哪個參照事件的一部分 | |||||
| status |
S | 1..1 | code | registered ｜ preliminary ｜ final ｜ amended + Binding: ObservationStatus (required): 檢驗檢查的狀態代碼；應填入所綁定值集中的其中一個代碼。 | ||||
  Slices for category |
S | 1..* | CodeableConceptTW | 概念（concept）－參照一個專門術語或只是純文字。 Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): 高層次的檢驗檢查分類；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。 | ||||
   category:twcore |
S | 0..* | CodeableConcept | Classification of type of observation Binding: 臺灣衛福部資訊處Observation Clinical Result類型值集 (required): 此slice綁定的值集之綁定強度雖為最高強度「要求使用(Requird)」，但因slice之特性，其不會限制僅能填此值集中的代碼，故在實作時也可使用其他值集的代碼。 | ||||
 code |
S | 1..1 | CodeableConceptTW | 概念（concept）－參照一個專門術語或只是純文字。 Binding: LOINCCodes (extensible): 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。 | ||||
 coding |
0..* | CodingTW | 由專門術語系統（terminology system）定義的代碼 | |||||
| subject |
S | 1..1 | Reference(TW Core Patient | TW Core Location | Group | Device) | 檢驗檢查有關的對象及（或）事物 | ||||
| focus |
0..* | Reference(Resource) | 當檢驗檢查並非有關於與病人本身，檢驗檢查是關於什麼。 | |||||
| encounter |
S | 0..1 | Reference(TW Core Encounter) | 檢驗檢查是哪一次就醫時執行的 | ||||
 effective[x] |
SC | 0..1 | 檢驗檢查執行日期或時間區間 tw-core-3: Datetime must be at least to day. | |||||
 effectiveDateTime |
dateTime S | |||||||
| effectivePeriod |
Period | |||||||
| effectiveTiming |
Timing | |||||||
| effectiveInstant |
instant | |||||||
| issued |
0..1 | instant | 此版本檢驗檢查完成的日期或時間 | |||||
| performer |
0..* | Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | TW Core PractitionerRole | TW Core CareTeam) | 誰負責這項檢驗檢查 | |||||
| value[x] |
SC | 0..1 | 檢驗檢查的實際結果 tw-core-5: SHALL use UCUM for coded quantity units. | |||||
| valueQuantity |
Quantity S | |||||||
| valueCodeableConcept |
CodeableConcept S | |||||||
| valueString |
string S | |||||||
| valueBoolean |
boolean | |||||||
| valueInteger |
integer | |||||||
| valueRange |
Range | |||||||
| valueRatio |
Ratio | |||||||
| valueSampledData |
SampledData | |||||||
| valueTime |
time | |||||||
| valueDateTime |
dateTime | |||||||
| valuePeriod |
Period | |||||||
| dataAbsentReason |
S | 0..1 | CodeableConceptTW | 缺少檢驗檢查結果的原因 Binding: DataAbsentReason (extensible): 代碼具體說明檢驗檢查結果缺少的原因；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。 | ||||
| interpretation |
0..* | CodeableConcept | 高、低、正常等 Binding: ObservationInterpretationCodes (extensible): 代碼指明檢驗檢查結果的解釋；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。 | |||||
| note |
0..* | Annotation | 關於此檢驗檢查之解說 | |||||
| bodySite |
0..1 | CodeableConcept | 接受檢驗檢查的身體部位。此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。 Binding: SNOMEDCTBodyStructures (example): 代碼說明解剖學位置，可能包含側邊；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。 | |||||
| method |
0..1 | CodeableConcept | 此檢驗檢查使用何種方法完成 Binding: ObservationMethods (example): 檢驗檢查的方法；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。 | |||||
| specimen |
0..1 | Reference(TW Core Specimen) | 此檢驗檢查的檢體 | |||||
| device |
0..1 | Reference(Device | DeviceMetric) | （測量）設備 | |||||
| referenceRange |
0..* | BackboneElement | 解釋結果值的指引。 obs-3：必須至少有低、高或文字表述。 | |||||
| low |
0..1 | SimpleQuantity | 參考範圍值的下限值，如果相關。 | |||||
| high |
0..1 | SimpleQuantity | 參考範圍值的上限值，如果相關。 | |||||
| type |
0..1 | CodeableConcept | 參考範圍值的限定詞 Binding: ObservationReferenceRangeMeaningCodes (preferred): 用以表述參考範圍值之含意的代碼；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。 | |||||
| appliesTo |
0..* | CodeableConcept | 參考範圍值是用適用的對象或人口群 Binding: ObservationReferenceRangeAppliesToCodes (example): 用以指明參考範圍值適用的對象或人口群之代碼；可參考所綁定代碼表，但此代碼表只是針對這個欄位的一個可能值的示例，不預期也不鼓勵使用者一定要使用此代碼表的代碼代碼表中的代碼。 | |||||
| age |
0..1 | Range | 適用的年齡範圍值，如果相關。 | |||||
| text |
0..1 | string | 檢驗檢查中以文字表述的參考範圍值 | |||||
| hasMember |
0..* | Reference(Observation | TW Core QuestionnaireResponse | MolecularSequence) | 屬於此組檢驗檢查的相關Resource | |||||
| derivedFrom |
0..* | Reference(TW Core DocumentReference | TW Core ImagingStudy | TW Core Media | TW Core QuestionnaireResponse | Observation | MolecularSequence) | 檢驗檢查源自哪些相關測量 | |||||
 component |
0..* | BackboneElement | 組成之（部分）檢驗檢查的檢驗結果 | |||||
 code |
1..1 | CodeableConcept | 組成之檢驗檢查的型別（代碼／型別） Binding: LOINCCodes (example): 代碼指明檢驗檢查的名稱；可參考LOINCCodes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。 | |||||
| value[x] |
0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | 組成之檢驗檢查的實際結果 | |||||
| dataAbsentReason |
0..1 | CodeableConcept | 為什麼缺少組成之檢驗檢查結果 Binding: DataAbsentReason (extensible): 代碼指明為什麼結果（Observation.value[x]）缺少；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。 | |||||
| interpretation |
0..* | CodeableConcept | 高、低、正常等。 Binding: ObservationInterpretationCodes (extensible): 用以指明檢驗檢查的解釋之代碼。應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。 | |||||
| referenceRange |
0..* | 解釋此組成之檢驗驗查的結果值之指引 | ||||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Observation.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard
| ||||
| Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1from the FHIR Standard | ||||
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | ||||
| Observation.category:twcore | required | TWObservationClinicalResultCategoryhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/observation-clinical-result-categoryfrom this IG | ||||
| Observation.code | extensible | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard | ||||
| Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methodsfrom the FHIR Standard | ||||
| Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaningfrom the FHIR Standard | ||||
| Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliestofrom the FHIR Standard | ||||
| Observation.component.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| tw-core-3 | error | Observation.effective[x] | Datetime must be at least to day. : $this is dateTime implies $this.toString().length() >= 10 | |
| tw-core-4 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present. : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
| tw-core-5 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org' |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Observation |
C | 0..* | Observation | 檢驗檢查，測量及簡單的判定。 dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present tw-core-4: If there is no component or hasMember element then either a value[x] or a data absent reason must be present. | ||||
| id |
Σ | 0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的Observation紀錄，通常又稱為邏輯性ID。 | ||||
| meta |
Σ | 0..1 | Meta | 此Observation Resource的metadata ele-1: All FHIR elements must have a @value or children | ||||
| implicitRules |
?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 ele-1: All FHIR elements must have a @value or children | ||||
| language |
0..1 | code | 用以表述Observation Resource內容的語言。 Binding: CommonLanguages (preferred): 人類語言；鼓勵使用CommonLanguages代碼表中的代碼，但不強制一定要使用此代碼表，你也可使用其他代碼表的代碼或單純以文字表示。
ele-1: All FHIR elements must have a @value or children Example Value: zh-TW | |||||
| text |
0..1 | Narrative | Observation Resource之內容摘要以供人閱讀 ele-1: All FHIR elements must have a @value or children | |||||
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| identifier |
Σ | 0..* | Identifier | 檢驗檢查的識別碼，通常為業務目的所使用的識別碼，例如：檢驗序號或單號。 ele-1: All FHIR elements must have a @value or children | ||||
| basedOn |
Σ | 0..* | Reference(TW Core CarePlan | DeviceRequest | ImmunizationRecommendation | TW Core MedicationRequest | NutritionOrder | TW Core ServiceRequest) | 依據的照護計畫／提議／醫令 ele-1: All FHIR elements must have a @value or children | ||||
| partOf |
Σ | 0..* | Reference(MedicationAdministration | TW Core MedicationDispense | TW Core MedicationStatement | TW Core Procedure | TW Core Immunization | TW Core ImagingStudy) | 此檢驗檢查是哪個參照事件的一部分 ele-1: All FHIR elements must have a @value or children | ||||
| status |
?!SΣ | 1..1 | code | registered ｜ preliminary ｜ final ｜ amended + Binding: ObservationStatus (required): 檢驗檢查的狀態代碼；應填入所綁定值集中的其中一個代碼。 ele-1: All FHIR elements must have a @value or children | ||||
| Slices for category |
S | 1..* | CodeableConceptTW | 概念（concept）－參照一個專門術語或只是純文字。 Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): 高層次的檢驗檢查分類；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。 ele-1: All FHIR elements must have a @value or children | ||||
| category:twcore |
S | 0..* | CodeableConcept | Classification of type of observation Binding: 臺灣衛福部資訊處Observation Clinical Result類型值集 (required): 此slice綁定的值集之綁定強度雖為最高強度「要求使用(Requird)」，但因slice之特性，其不會限制僅能填此值集中的代碼，故在實作時也可使用其他值集的代碼。 ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConceptTW | 概念（concept）－參照一個專門術語或只是純文字。 Binding: LOINCCodes (extensible): 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。 ele-1: All FHIR elements must have a @value or children | ||||
| coding |
S | 0..* | CodingTW | 由專門術語系統（terminology system）定義的代碼 ele-1: All FHIR elements must have a @value or children | ||||
| text |
SΣ | 0..1 | string | 概念的文字表示法 ele-1: All FHIR elements must have a @value or children | ||||
| subject |
SΣ | 1..1 | Reference(TW Core Patient | TW Core Location | Group | Device) | 檢驗檢查有關的對象及（或）事物 ele-1: All FHIR elements must have a @value or children | ||||
| focus |
Σ | 0..* | Reference(Resource) | 當檢驗檢查並非有關於與病人本身，檢驗檢查是關於什麼。 ele-1: All FHIR elements must have a @value or children | ||||
| encounter |
SΣ | 0..1 | Reference(TW Core Encounter) | 檢驗檢查是哪一次就醫時執行的 ele-1: All FHIR elements must have a @value or children | ||||
| effective[x] |
SΣC | 0..1 | 檢驗檢查執行日期或時間區間 ele-1: All FHIR elements must have a @value or children tw-core-3: Datetime must be at least to day. | |||||
| effectiveDateTime |
dateTime | |||||||
| issued |
Σ | 0..1 | instant | 此版本檢驗檢查完成的日期或時間 ele-1: All FHIR elements must have a @value or children | ||||
| performer |
Σ | 0..* | Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | TW Core PractitionerRole | TW Core CareTeam) | 誰負責這項檢驗檢查 ele-1: All FHIR elements must have a @value or children | ||||
| value[x] |
SΣC | 0..1 | 檢驗檢查的實際結果 ele-1: All FHIR elements must have a @value or children tw-core-5: SHALL use UCUM for coded quantity units. | |||||
| valueQuantity |
Quantity | |||||||
| valueCodeableConcept |
CodeableConcept | |||||||
| valueString |
string | |||||||
| dataAbsentReason |
S | 0..1 | CodeableConceptTW | 缺少檢驗檢查結果的原因 Binding: DataAbsentReason (extensible): 代碼具體說明檢驗檢查結果缺少的原因；應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。 ele-1: All FHIR elements must have a @value or children | ||||
| interpretation |
0..* | CodeableConcept | 高、低、正常等 Binding: ObservationInterpretationCodes (extensible): 代碼指明檢驗檢查結果的解釋；應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。 ele-1: All FHIR elements must have a @value or children | |||||
| note |
0..* | Annotation | 關於此檢驗檢查之解說 ele-1: All FHIR elements must have a @value or children | |||||
| bodySite |
0..1 | CodeableConcept | 接受檢驗檢查的身體部位。此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。 Binding: SNOMEDCTBodyStructures (example): 代碼說明解剖學位置，可能包含側邊；應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。 ele-1: All FHIR elements must have a @value or children | |||||
| method |
0..1 | CodeableConcept | 此檢驗檢查使用何種方法完成 Binding: ObservationMethods (example): 檢驗檢查的方法；應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。 ele-1: All FHIR elements must have a @value or children | |||||
| specimen |
0..1 | Reference(TW Core Specimen) | 此檢驗檢查的檢體 ele-1: All FHIR elements must have a @value or children | |||||
| device |
0..1 | Reference(Device | DeviceMetric) | （測量）設備 ele-1: All FHIR elements must have a @value or children | |||||
| referenceRange |
C | 0..* | BackboneElement | 解釋結果值的指引。
obs-3：必須至少有低、高或文字表述。 ele-1: All FHIR elements must have a @value or children obs-3: Must have at least a low or a high or text | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| low |
C | 0..1 | SimpleQuantity | 參考範圍值的下限值，如果相關。 ele-1: All FHIR elements must have a @value or children | ||||
| high |
C | 0..1 | SimpleQuantity | 參考範圍值的上限值，如果相關。 ele-1: All FHIR elements must have a @value or children | ||||
| type |
0..1 | CodeableConcept | 參考範圍值的限定詞 Binding: ObservationReferenceRangeMeaningCodes (preferred): 用以表述參考範圍值之含意的代碼；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。 ele-1: All FHIR elements must have a @value or children | |||||
| appliesTo |
0..* | CodeableConcept | 參考範圍值是用適用的對象或人口群 Binding: ObservationReferenceRangeAppliesToCodes (example): 用以指明參考範圍值適用的對象或人口群之代碼；可參考所綁定代碼表，但此代碼表只是針對這個欄位的一個可能值的示例，不預期也不鼓勵使用者一定要使用此代碼表的代碼代碼表中的代碼。 ele-1: All FHIR elements must have a @value or children | |||||
| age |
0..1 | Range | 適用的年齡範圍值，如果相關。 ele-1: All FHIR elements must have a @value or children | |||||
| text |
0..1 | string | 檢驗檢查中以文字表述的參考範圍值 ele-1: All FHIR elements must have a @value or children | |||||
| hasMember |
Σ | 0..* | Reference(Observation | TW Core QuestionnaireResponse | MolecularSequence) | 屬於此組檢驗檢查的相關Resource ele-1: All FHIR elements must have a @value or children | ||||
| derivedFrom |
Σ | 0..* | Reference(TW Core DocumentReference | TW Core ImagingStudy | TW Core Media | TW Core QuestionnaireResponse | Observation | MolecularSequence) | 檢驗檢查源自哪些相關測量 ele-1: All FHIR elements must have a @value or children | ||||
| component |
Σ | 0..* | BackboneElement | 組成之（部分）檢驗檢查的檢驗結果 ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| code |
Σ | 1..1 | CodeableConcept | 組成之檢驗檢查的型別（代碼／型別） Binding: LOINCCodes (example): 代碼指明檢驗檢查的名稱；可參考LOINCCodes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。 ele-1: All FHIR elements must have a @value or children | ||||
| value[x] |
Σ | 0..1 | 組成之檢驗檢查的實際結果 ele-1: All FHIR elements must have a @value or children | |||||
| valueQuantity |
Quantity | |||||||
| valueCodeableConcept |
CodeableConcept | |||||||
| valueString |
string | |||||||
| valueBoolean |
boolean | |||||||
| valueInteger |
integer | |||||||
| valueRange |
Range | |||||||
| valueRatio |
Ratio | |||||||
| valueSampledData |
SampledData | |||||||
| valueTime |
time | |||||||
| valueDateTime |
dateTime | |||||||
| valuePeriod |
Period | |||||||
| dataAbsentReason |
C | 0..1 | CodeableConcept | 為什麼缺少組成之檢驗檢查結果 Binding: DataAbsentReason (extensible): 代碼指明為什麼結果（Observation.value[x]）缺少；應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。 ele-1: All FHIR elements must have a @value or children | ||||
| interpretation |
0..* | CodeableConcept | 高、低、正常等。 Binding: ObservationInterpretationCodes (extensible): 用以指明檢驗檢查的解釋之代碼。應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。 ele-1: All FHIR elements must have a @value or children | |||||
| referenceRange |
0..* | See referenceRange (Observation) | 解釋此組成之檢驗驗查的結果值之指引 ele-1: All FHIR elements must have a @value or children | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Observation.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard
| ||||
| Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1from the FHIR Standard | ||||
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | ||||
| Observation.category:twcore | required | TWObservationClinicalResultCategoryhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/observation-clinical-result-categoryfrom this IG | ||||
| Observation.code | extensible | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard | ||||
| Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methodsfrom the FHIR Standard | ||||
| Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaningfrom the FHIR Standard | ||||
| Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliestofrom the FHIR Standard | ||||
| Observation.component.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
| tw-core-3 | error | Observation.effective[x] | Datetime must be at least to day. : $this is dateTime implies $this.toString().length() >= 10 | |
| tw-core-4 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present. : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
| tw-core-5 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org' |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Observation |
C | 0..* | Observation | 檢驗檢查，測量及簡單的判定。 obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present tw-core-4: If there is no component or hasMember element then either a value[x] or a data absent reason must be present. | ||||
| id |
Σ | 0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的Observation紀錄，通常又稱為邏輯性ID。 | ||||
| meta |
Σ | 0..1 | Meta | 此Observation Resource的metadata | ||||
| implicitRules |
?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 | ||||
| language |
0..1 | code | 用以表述Observation Resource內容的語言。 Binding: CommonLanguages (preferred): 人類語言；鼓勵使用CommonLanguages代碼表中的代碼，但不強制一定要使用此代碼表，你也可使用其他代碼表的代碼或單純以文字表示。
Example Value: zh-TW | |||||
| text |
0..1 | Narrative | Observation Resource之內容摘要以供人閱讀 | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
 extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | 檢驗檢查的識別碼，通常為業務目的所使用的識別碼，例如：檢驗序號或單號。 | ||||
| basedOn |
Σ | 0..* | Reference(TW Core CarePlan | DeviceRequest | ImmunizationRecommendation | TW Core MedicationRequest | NutritionOrder | TW Core ServiceRequest) | 依據的照護計畫／提議／醫令 | ||||
| partOf |
Σ | 0..* | Reference(MedicationAdministration | TW Core MedicationDispense | TW Core MedicationStatement | TW Core Procedure | TW Core Immunization | TW Core ImagingStudy) | 此檢驗檢查是哪個參照事件的一部分 | ||||
| status |
?!SΣ | 1..1 | code | registered ｜ preliminary ｜ final ｜ amended + Binding: ObservationStatus (required): 檢驗檢查的狀態代碼；應填入所綁定值集中的其中一個代碼。 | ||||
| Slices for category |
S | 1..* | CodeableConceptTW | 概念（concept）－參照一個專門術語或只是純文字。 Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): 高層次的檢驗檢查分類；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。 | ||||
| category:twcore |
S | 0..* | CodeableConcept | Classification of type of observation Binding: 臺灣衛福部資訊處Observation Clinical Result類型值集 (required): 此slice綁定的值集之綁定強度雖為最高強度「要求使用(Requird)」，但因slice之特性，其不會限制僅能填此值集中的代碼，故在實作時也可使用其他值集的代碼。 | ||||
| code |
S | 1..1 | CodeableConceptTW | 概念（concept）－參照一個專門術語或只是純文字。 Binding: LOINCCodes (extensible): 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。 | ||||
| id |
0..1 | string | 唯一可識別ID，以供資料項目間相互參照。 | |||||
| extension |
0..* | Extension | 擴充的資料項目 Slice: Unordered, Open by value:url | |||||
| coding |
S | 0..* | CodingTW | 由專門術語系統（terminology system）定義的代碼 | ||||
| text |
SΣ | 0..1 | string | 概念的文字表示法 | ||||
| subject |
SΣ | 1..1 | Reference(TW Core Patient | TW Core Location | Group | Device) | 檢驗檢查有關的對象及（或）事物 | ||||
| focus |
Σ | 0..* | Reference(Resource) | 當檢驗檢查並非有關於與病人本身，檢驗檢查是關於什麼。 | ||||
| encounter |
SΣ | 0..1 | Reference(TW Core Encounter) | 檢驗檢查是哪一次就醫時執行的 | ||||
| effective[x] |
SΣC | 0..1 | 檢驗檢查執行日期或時間區間 tw-core-3: Datetime must be at least to day. | |||||
| effectiveDateTime |
dateTime S | |||||||
| effectivePeriod |
Period | |||||||
| effectiveTiming |
Timing | |||||||
| effectiveInstant |
instant | |||||||
| issued |
Σ | 0..1 | instant | 此版本檢驗檢查完成的日期或時間 | ||||
| performer |
Σ | 0..* | Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | TW Core PractitionerRole | TW Core CareTeam) | 誰負責這項檢驗檢查 | ||||
| value[x] |
SΣC | 0..1 | 檢驗檢查的實際結果 tw-core-5: SHALL use UCUM for coded quantity units. | |||||
| valueQuantity |
Quantity S | |||||||
| valueCodeableConcept |
CodeableConcept S | |||||||
| valueString |
string S | |||||||
| valueBoolean |
boolean | |||||||
| valueInteger |
integer | |||||||
| valueRange |
Range | |||||||
| valueRatio |
Ratio | |||||||
| valueSampledData |
SampledData | |||||||
| valueTime |
time | |||||||
| valueDateTime |
dateTime | |||||||
| valuePeriod |
Period | |||||||
| dataAbsentReason |
S | 0..1 | CodeableConceptTW | 缺少檢驗檢查結果的原因 Binding: DataAbsentReason (extensible): 代碼具體說明檢驗檢查結果缺少的原因；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。 | ||||
| interpretation |
0..* | CodeableConcept | 高、低、正常等 Binding: ObservationInterpretationCodes (extensible): 代碼指明檢驗檢查結果的解釋；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。 | |||||
| note |
0..* | Annotation | 關於此檢驗檢查之解說 | |||||
| bodySite |
0..1 | CodeableConcept | 接受檢驗檢查的身體部位。此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。 Binding: SNOMEDCTBodyStructures (example): 代碼說明解剖學位置，可能包含側邊；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。 | |||||
| method |
0..1 | CodeableConcept | 此檢驗檢查使用何種方法完成 Binding: ObservationMethods (example): 檢驗檢查的方法；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。 | |||||
| specimen |
0..1 | Reference(TW Core Specimen) | 此檢驗檢查的檢體 | |||||
| device |
0..1 | Reference(Device | DeviceMetric) | （測量）設備 | |||||
| referenceRange |
C | 0..* | BackboneElement | 解釋結果值的指引。
obs-3：必須至少有低、高或文字表述。 obs-3: Must have at least a low or a high or text | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| low |
C | 0..1 | SimpleQuantity | 參考範圍值的下限值，如果相關。 | ||||
| high |
C | 0..1 | SimpleQuantity | 參考範圍值的上限值，如果相關。 | ||||
| type |
0..1 | CodeableConcept | 參考範圍值的限定詞 Binding: ObservationReferenceRangeMeaningCodes (preferred): 用以表述參考範圍值之含意的代碼；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。 | |||||
| appliesTo |
0..* | CodeableConcept | 參考範圍值是用適用的對象或人口群 Binding: ObservationReferenceRangeAppliesToCodes (example): 用以指明參考範圍值適用的對象或人口群之代碼；可參考所綁定代碼表，但此代碼表只是針對這個欄位的一個可能值的示例，不預期也不鼓勵使用者一定要使用此代碼表的代碼代碼表中的代碼。 | |||||
| age |
0..1 | Range | 適用的年齡範圍值，如果相關。 | |||||
| text |
0..1 | string | 檢驗檢查中以文字表述的參考範圍值 | |||||
| hasMember |
Σ | 0..* | Reference(Observation | TW Core QuestionnaireResponse | MolecularSequence) | 屬於此組檢驗檢查的相關Resource | ||||
| derivedFrom |
Σ | 0..* | Reference(TW Core DocumentReference | TW Core ImagingStudy | TW Core Media | TW Core QuestionnaireResponse | Observation | MolecularSequence) | 檢驗檢查源自哪些相關測量 | ||||
| component |
Σ | 0..* | BackboneElement | 組成之（部分）檢驗檢查的檢驗結果 | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code |
Σ | 1..1 | CodeableConcept | 組成之檢驗檢查的型別（代碼／型別） Binding: LOINCCodes (example): 代碼指明檢驗檢查的名稱；可參考LOINCCodes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。 | ||||
| value[x] |
Σ | 0..1 | 組成之檢驗檢查的實際結果 | |||||
| valueQuantity |
Quantity | |||||||
| valueCodeableConcept |
CodeableConcept | |||||||
| valueString |
string | |||||||
| valueBoolean |
boolean | |||||||
| valueInteger |
integer | |||||||
| valueRange |
Range | |||||||
| valueRatio |
Ratio | |||||||
| valueSampledData |
SampledData | |||||||
| valueTime |
time | |||||||
| valueDateTime |
dateTime | |||||||
| valuePeriod |
Period | |||||||
| dataAbsentReason |
C | 0..1 | CodeableConcept | 為什麼缺少組成之檢驗檢查結果 Binding: DataAbsentReason (extensible): 代碼指明為什麼結果（Observation.value[x]）缺少；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。 | ||||
| interpretation |
0..* | CodeableConcept | 高、低、正常等。 Binding: ObservationInterpretationCodes (extensible): 用以指明檢驗檢查的解釋之代碼。應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。 | |||||
| referenceRange |
0..* | See referenceRange (Observation) | 解釋此組成之檢驗驗查的結果值之指引 | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Observation.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard
| ||||
| Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1from the FHIR Standard | ||||
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | ||||
| Observation.category:twcore | required | TWObservationClinicalResultCategoryhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/observation-clinical-result-categoryfrom this IG | ||||
| Observation.code | extensible | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard | ||||
| Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methodsfrom the FHIR Standard | ||||
| Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaningfrom the FHIR Standard | ||||
| Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliestofrom the FHIR Standard | ||||
| Observation.component.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
| tw-core-3 | error | Observation.effective[x] | Datetime must be at least to day. : $this is dateTime implies $this.toString().length() >= 10 | |
| tw-core-4 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present. : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
| tw-core-5 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org' |
This structure is derived from Observation
Summary
Mandatory: 2 elements
Must-Support: 9 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Observation
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Observation |
C | 0..* | Observation | 檢驗檢查，測量及簡單的判定。 tw-core-4: If there is no component or hasMember element then either a value[x] or a data absent reason must be present. | ||||
| id |
0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的Observation紀錄，通常又稱為邏輯性ID。 | |||||
| meta |
0..1 | Meta | 此Observation Resource的metadata | |||||
| implicitRules |
0..1 | uri | 創建此內容所依據的一組規則 | |||||
| language |
0..1 | code | 用以表述Observation Resource內容的語言。 Binding: CommonLanguages (preferred): 人類語言；鼓勵使用CommonLanguages代碼表中的代碼，但不強制一定要使用此代碼表，你也可使用其他代碼表的代碼或單純以文字表示。
Example Value: zh-TW | |||||
| text |
0..1 | Narrative | Observation Resource之內容摘要以供人閱讀 | |||||
| identifier |
0..* | Identifier | 檢驗檢查的識別碼，通常為業務目的所使用的識別碼，例如：檢驗序號或單號。 | |||||
| basedOn |
0..* | Reference(TW Core CarePlan | DeviceRequest | ImmunizationRecommendation | TW Core MedicationRequest | NutritionOrder | TW Core ServiceRequest) | 依據的照護計畫／提議／醫令 | |||||
| partOf |
0..* | Reference(MedicationAdministration | TW Core MedicationDispense | TW Core MedicationStatement | TW Core Procedure | TW Core Immunization | TW Core ImagingStudy) | 此檢驗檢查是哪個參照事件的一部分 | |||||
| status |
S | 1..1 | code | registered ｜ preliminary ｜ final ｜ amended + Binding: ObservationStatus (required): 檢驗檢查的狀態代碼；應填入所綁定值集中的其中一個代碼。 | ||||
| Slices for category |
S | 1..* | CodeableConceptTW | 概念（concept）－參照一個專門術語或只是純文字。 Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): 高層次的檢驗檢查分類；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。 | ||||
| category:twcore |
S | 0..* | CodeableConcept | Classification of type of observation Binding: 臺灣衛福部資訊處Observation Clinical Result類型值集 (required): 此slice綁定的值集之綁定強度雖為最高強度「要求使用(Requird)」，但因slice之特性，其不會限制僅能填此值集中的代碼，故在實作時也可使用其他值集的代碼。 | ||||
| code |
S | 1..1 | CodeableConceptTW | 概念（concept）－參照一個專門術語或只是純文字。 Binding: LOINCCodes (extensible): 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。 | ||||
| coding |
0..* | CodingTW | 由專門術語系統（terminology system）定義的代碼 | |||||
| subject |
S | 1..1 | Reference(TW Core Patient | TW Core Location | Group | Device) | 檢驗檢查有關的對象及（或）事物 | ||||
| focus |
0..* | Reference(Resource) | 當檢驗檢查並非有關於與病人本身，檢驗檢查是關於什麼。 | |||||
| encounter |
S | 0..1 | Reference(TW Core Encounter) | 檢驗檢查是哪一次就醫時執行的 | ||||
| effective[x] |
SC | 0..1 | 檢驗檢查執行日期或時間區間 tw-core-3: Datetime must be at least to day. | |||||
| effectiveDateTime |
dateTime S | |||||||
| effectivePeriod |
Period | |||||||
| effectiveTiming |
Timing | |||||||
| effectiveInstant |
instant | |||||||
| issued |
0..1 | instant | 此版本檢驗檢查完成的日期或時間 | |||||
| performer |
0..* | Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | TW Core PractitionerRole | TW Core CareTeam) | 誰負責這項檢驗檢查 | |||||
| value[x] |
SC | 0..1 | 檢驗檢查的實際結果 tw-core-5: SHALL use UCUM for coded quantity units. | |||||
| valueQuantity |
Quantity S | |||||||
| valueCodeableConcept |
CodeableConcept S | |||||||
| valueString |
string S | |||||||
| valueBoolean |
boolean | |||||||
| valueInteger |
integer | |||||||
| valueRange |
Range | |||||||
| valueRatio |
Ratio | |||||||
| valueSampledData |
SampledData | |||||||
| valueTime |
time | |||||||
| valueDateTime |
dateTime | |||||||
| valuePeriod |
Period | |||||||
| dataAbsentReason |
S | 0..1 | CodeableConceptTW | 缺少檢驗檢查結果的原因 Binding: DataAbsentReason (extensible): 代碼具體說明檢驗檢查結果缺少的原因；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。 | ||||
| interpretation |
0..* | CodeableConcept | 高、低、正常等 Binding: ObservationInterpretationCodes (extensible): 代碼指明檢驗檢查結果的解釋；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。 | |||||
| note |
0..* | Annotation | 關於此檢驗檢查之解說 | |||||
| bodySite |
0..1 | CodeableConcept | 接受檢驗檢查的身體部位。此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。 Binding: SNOMEDCTBodyStructures (example): 代碼說明解剖學位置，可能包含側邊；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。 | |||||
| method |
0..1 | CodeableConcept | 此檢驗檢查使用何種方法完成 Binding: ObservationMethods (example): 檢驗檢查的方法；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。 | |||||
| specimen |
0..1 | Reference(TW Core Specimen) | 此檢驗檢查的檢體 | |||||
| device |
0..1 | Reference(Device | DeviceMetric) | （測量）設備 | |||||
| referenceRange |
0..* | BackboneElement | 解釋結果值的指引。 obs-3：必須至少有低、高或文字表述。 | |||||
| low |
0..1 | SimpleQuantity | 參考範圍值的下限值，如果相關。 | |||||
| high |
0..1 | SimpleQuantity | 參考範圍值的上限值，如果相關。 | |||||
| type |
0..1 | CodeableConcept | 參考範圍值的限定詞 Binding: ObservationReferenceRangeMeaningCodes (preferred): 用以表述參考範圍值之含意的代碼；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。 | |||||
| appliesTo |
0..* | CodeableConcept | 參考範圍值是用適用的對象或人口群 Binding: ObservationReferenceRangeAppliesToCodes (example): 用以指明參考範圍值適用的對象或人口群之代碼；可參考所綁定代碼表，但此代碼表只是針對這個欄位的一個可能值的示例，不預期也不鼓勵使用者一定要使用此代碼表的代碼代碼表中的代碼。 | |||||
| age |
0..1 | Range | 適用的年齡範圍值，如果相關。 | |||||
| text |
0..1 | string | 檢驗檢查中以文字表述的參考範圍值 | |||||
| hasMember |
0..* | Reference(Observation | TW Core QuestionnaireResponse | MolecularSequence) | 屬於此組檢驗檢查的相關Resource | |||||
| derivedFrom |
0..* | Reference(TW Core DocumentReference | TW Core ImagingStudy | TW Core Media | TW Core QuestionnaireResponse | Observation | MolecularSequence) | 檢驗檢查源自哪些相關測量 | |||||
| component |
0..* | BackboneElement | 組成之（部分）檢驗檢查的檢驗結果 | |||||
| code |
1..1 | CodeableConcept | 組成之檢驗檢查的型別（代碼／型別） Binding: LOINCCodes (example): 代碼指明檢驗檢查的名稱；可參考LOINCCodes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。 | |||||
| value[x] |
0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | 組成之檢驗檢查的實際結果 | |||||
| dataAbsentReason |
0..1 | CodeableConcept | 為什麼缺少組成之檢驗檢查結果 Binding: DataAbsentReason (extensible): 代碼指明為什麼結果（Observation.value[x]）缺少；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。 | |||||
| interpretation |
0..* | CodeableConcept | 高、低、正常等。 Binding: ObservationInterpretationCodes (extensible): 用以指明檢驗檢查的解釋之代碼。應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。 | |||||
| referenceRange |
0..* | 解釋此組成之檢驗驗查的結果值之指引 | ||||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Observation.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard
| ||||
| Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1from the FHIR Standard | ||||
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | ||||
| Observation.category:twcore | required | TWObservationClinicalResultCategoryhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/observation-clinical-result-categoryfrom this IG | ||||
| Observation.code | extensible | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard | ||||
| Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methodsfrom the FHIR Standard | ||||
| Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaningfrom the FHIR Standard | ||||
| Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliestofrom the FHIR Standard | ||||
| Observation.component.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| tw-core-3 | error | Observation.effective[x] | Datetime must be at least to day. : $this is dateTime implies $this.toString().length() >= 10 | |
| tw-core-4 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present. : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
| tw-core-5 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org' |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Observation |
C | 0..* | Observation | 檢驗檢查，測量及簡單的判定。 dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present tw-core-4: If there is no component or hasMember element then either a value[x] or a data absent reason must be present. | ||||
| id |
Σ | 0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的Observation紀錄，通常又稱為邏輯性ID。 | ||||
| meta |
Σ | 0..1 | Meta | 此Observation Resource的metadata ele-1: All FHIR elements must have a @value or children | ||||
| implicitRules |
?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 ele-1: All FHIR elements must have a @value or children | ||||
| language |
0..1 | code | 用以表述Observation Resource內容的語言。 Binding: CommonLanguages (preferred): 人類語言；鼓勵使用CommonLanguages代碼表中的代碼，但不強制一定要使用此代碼表，你也可使用其他代碼表的代碼或單純以文字表示。
ele-1: All FHIR elements must have a @value or children Example Value: zh-TW | |||||
| text |
0..1 | Narrative | Observation Resource之內容摘要以供人閱讀 ele-1: All FHIR elements must have a @value or children | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| identifier |
Σ | 0..* | Identifier | 檢驗檢查的識別碼，通常為業務目的所使用的識別碼，例如：檢驗序號或單號。 ele-1: All FHIR elements must have a @value or children | ||||
| basedOn |
Σ | 0..* | Reference(TW Core CarePlan | DeviceRequest | ImmunizationRecommendation | TW Core MedicationRequest | NutritionOrder | TW Core ServiceRequest) | 依據的照護計畫／提議／醫令 ele-1: All FHIR elements must have a @value or children | ||||
| partOf |
Σ | 0..* | Reference(MedicationAdministration | TW Core MedicationDispense | TW Core MedicationStatement | TW Core Procedure | TW Core Immunization | TW Core ImagingStudy) | 此檢驗檢查是哪個參照事件的一部分 ele-1: All FHIR elements must have a @value or children | ||||
| status |
?!SΣ | 1..1 | code | registered ｜ preliminary ｜ final ｜ amended + Binding: ObservationStatus (required): 檢驗檢查的狀態代碼；應填入所綁定值集中的其中一個代碼。 ele-1: All FHIR elements must have a @value or children | ||||
| Slices for category |
S | 1..* | CodeableConceptTW | 概念（concept）－參照一個專門術語或只是純文字。 Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): 高層次的檢驗檢查分類；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。 ele-1: All FHIR elements must have a @value or children | ||||
| category:twcore |
S | 0..* | CodeableConcept | Classification of type of observation Binding: 臺灣衛福部資訊處Observation Clinical Result類型值集 (required): 此slice綁定的值集之綁定強度雖為最高強度「要求使用(Requird)」，但因slice之特性，其不會限制僅能填此值集中的代碼，故在實作時也可使用其他值集的代碼。 ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 1..1 | CodeableConceptTW | 概念（concept）－參照一個專門術語或只是純文字。 Binding: LOINCCodes (extensible): 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。 ele-1: All FHIR elements must have a @value or children | ||||
| coding |
S | 0..* | CodingTW | 由專門術語系統（terminology system）定義的代碼 ele-1: All FHIR elements must have a @value or children | ||||
| text |
SΣ | 0..1 | string | 概念的文字表示法 ele-1: All FHIR elements must have a @value or children | ||||
| subject |
SΣ | 1..1 | Reference(TW Core Patient | TW Core Location | Group | Device) | 檢驗檢查有關的對象及（或）事物 ele-1: All FHIR elements must have a @value or children | ||||
| focus |
Σ | 0..* | Reference(Resource) | 當檢驗檢查並非有關於與病人本身，檢驗檢查是關於什麼。 ele-1: All FHIR elements must have a @value or children | ||||
| encounter |
SΣ | 0..1 | Reference(TW Core Encounter) | 檢驗檢查是哪一次就醫時執行的 ele-1: All FHIR elements must have a @value or children | ||||
| effective[x] |
SΣC | 0..1 | 檢驗檢查執行日期或時間區間 ele-1: All FHIR elements must have a @value or children tw-core-3: Datetime must be at least to day. | |||||
| effectiveDateTime |
dateTime | |||||||
| issued |
Σ | 0..1 | instant | 此版本檢驗檢查完成的日期或時間 ele-1: All FHIR elements must have a @value or children | ||||
| performer |
Σ | 0..* | Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | TW Core PractitionerRole | TW Core CareTeam) | 誰負責這項檢驗檢查 ele-1: All FHIR elements must have a @value or children | ||||
| value[x] |
SΣC | 0..1 | 檢驗檢查的實際結果 ele-1: All FHIR elements must have a @value or children tw-core-5: SHALL use UCUM for coded quantity units. | |||||
| valueQuantity |
Quantity | |||||||
| valueCodeableConcept |
CodeableConcept | |||||||
| valueString |
string | |||||||
| dataAbsentReason |
S | 0..1 | CodeableConceptTW | 缺少檢驗檢查結果的原因 Binding: DataAbsentReason (extensible): 代碼具體說明檢驗檢查結果缺少的原因；應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。 ele-1: All FHIR elements must have a @value or children | ||||
| interpretation |
0..* | CodeableConcept | 高、低、正常等 Binding: ObservationInterpretationCodes (extensible): 代碼指明檢驗檢查結果的解釋；應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。 ele-1: All FHIR elements must have a @value or children | |||||
| note |
0..* | Annotation | 關於此檢驗檢查之解說 ele-1: All FHIR elements must have a @value or children | |||||
| bodySite |
0..1 | CodeableConcept | 接受檢驗檢查的身體部位。此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。 Binding: SNOMEDCTBodyStructures (example): 代碼說明解剖學位置，可能包含側邊；應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。 ele-1: All FHIR elements must have a @value or children | |||||
| method |
0..1 | CodeableConcept | 此檢驗檢查使用何種方法完成 Binding: ObservationMethods (example): 檢驗檢查的方法；應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。 ele-1: All FHIR elements must have a @value or children | |||||
| specimen |
0..1 | Reference(TW Core Specimen) | 此檢驗檢查的檢體 ele-1: All FHIR elements must have a @value or children | |||||
| device |
0..1 | Reference(Device | DeviceMetric) | （測量）設備 ele-1: All FHIR elements must have a @value or children | |||||
| referenceRange |
C | 0..* | BackboneElement | 解釋結果值的指引。
obs-3：必須至少有低、高或文字表述。 ele-1: All FHIR elements must have a @value or children obs-3: Must have at least a low or a high or text | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| low |
C | 0..1 | SimpleQuantity | 參考範圍值的下限值，如果相關。 ele-1: All FHIR elements must have a @value or children | ||||
| high |
C | 0..1 | SimpleQuantity | 參考範圍值的上限值，如果相關。 ele-1: All FHIR elements must have a @value or children | ||||
| type |
0..1 | CodeableConcept | 參考範圍值的限定詞 Binding: ObservationReferenceRangeMeaningCodes (preferred): 用以表述參考範圍值之含意的代碼；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。 ele-1: All FHIR elements must have a @value or children | |||||
| appliesTo |
0..* | CodeableConcept | 參考範圍值是用適用的對象或人口群 Binding: ObservationReferenceRangeAppliesToCodes (example): 用以指明參考範圍值適用的對象或人口群之代碼；可參考所綁定代碼表，但此代碼表只是針對這個欄位的一個可能值的示例，不預期也不鼓勵使用者一定要使用此代碼表的代碼代碼表中的代碼。 ele-1: All FHIR elements must have a @value or children | |||||
| age |
0..1 | Range | 適用的年齡範圍值，如果相關。 ele-1: All FHIR elements must have a @value or children | |||||
| text |
0..1 | string | 檢驗檢查中以文字表述的參考範圍值 ele-1: All FHIR elements must have a @value or children | |||||
| hasMember |
Σ | 0..* | Reference(Observation | TW Core QuestionnaireResponse | MolecularSequence) | 屬於此組檢驗檢查的相關Resource ele-1: All FHIR elements must have a @value or children | ||||
| derivedFrom |
Σ | 0..* | Reference(TW Core DocumentReference | TW Core ImagingStudy | TW Core Media | TW Core QuestionnaireResponse | Observation | MolecularSequence) | 檢驗檢查源自哪些相關測量 ele-1: All FHIR elements must have a @value or children | ||||
| component |
Σ | 0..* | BackboneElement | 組成之（部分）檢驗檢查的檢驗結果 ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| code |
Σ | 1..1 | CodeableConcept | 組成之檢驗檢查的型別（代碼／型別） Binding: LOINCCodes (example): 代碼指明檢驗檢查的名稱；可參考LOINCCodes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。 ele-1: All FHIR elements must have a @value or children | ||||
| value[x] |
Σ | 0..1 | 組成之檢驗檢查的實際結果 ele-1: All FHIR elements must have a @value or children | |||||
| valueQuantity |
Quantity | |||||||
| valueCodeableConcept |
CodeableConcept | |||||||
| valueString |
string | |||||||
| valueBoolean |
boolean | |||||||
| valueInteger |
integer | |||||||
| valueRange |
Range | |||||||
| valueRatio |
Ratio | |||||||
| valueSampledData |
SampledData | |||||||
| valueTime |
time | |||||||
| valueDateTime |
dateTime | |||||||
| valuePeriod |
Period | |||||||
| dataAbsentReason |
C | 0..1 | CodeableConcept | 為什麼缺少組成之檢驗檢查結果 Binding: DataAbsentReason (extensible): 代碼指明為什麼結果（Observation.value[x]）缺少；應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。 ele-1: All FHIR elements must have a @value or children | ||||
| interpretation |
0..* | CodeableConcept | 高、低、正常等。 Binding: ObservationInterpretationCodes (extensible): 用以指明檢驗檢查的解釋之代碼。應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。 ele-1: All FHIR elements must have a @value or children | |||||
| referenceRange |
0..* | See referenceRange (Observation) | 解釋此組成之檢驗驗查的結果值之指引 ele-1: All FHIR elements must have a @value or children | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Observation.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard
| ||||
| Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1from the FHIR Standard | ||||
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | ||||
| Observation.category:twcore | required | TWObservationClinicalResultCategoryhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/observation-clinical-result-categoryfrom this IG | ||||
| Observation.code | extensible | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard | ||||
| Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methodsfrom the FHIR Standard | ||||
| Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaningfrom the FHIR Standard | ||||
| Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliestofrom the FHIR Standard | ||||
| Observation.component.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
| tw-core-3 | error | Observation.effective[x] | Datetime must be at least to day. : $this is dateTime implies $this.toString().length() >= 10 | |
| tw-core-4 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present. : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
| tw-core-5 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org' |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Observation |
C | 0..* | Observation | 檢驗檢查，測量及簡單的判定。 obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present tw-core-4: If there is no component or hasMember element then either a value[x] or a data absent reason must be present. | ||||
| id |
Σ | 0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的Observation紀錄，通常又稱為邏輯性ID。 | ||||
| meta |
Σ | 0..1 | Meta | 此Observation Resource的metadata | ||||
| implicitRules |
?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 | ||||
| language |
0..1 | code | 用以表述Observation Resource內容的語言。 Binding: CommonLanguages (preferred): 人類語言；鼓勵使用CommonLanguages代碼表中的代碼，但不強制一定要使用此代碼表，你也可使用其他代碼表的代碼或單純以文字表示。
Example Value: zh-TW | |||||
| text |
0..1 | Narrative | Observation Resource之內容摘要以供人閱讀 | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | 檢驗檢查的識別碼，通常為業務目的所使用的識別碼，例如：檢驗序號或單號。 | ||||
| basedOn |
Σ | 0..* | Reference(TW Core CarePlan | DeviceRequest | ImmunizationRecommendation | TW Core MedicationRequest | NutritionOrder | TW Core ServiceRequest) | 依據的照護計畫／提議／醫令 | ||||
| partOf |
Σ | 0..* | Reference(MedicationAdministration | TW Core MedicationDispense | TW Core MedicationStatement | TW Core Procedure | TW Core Immunization | TW Core ImagingStudy) | 此檢驗檢查是哪個參照事件的一部分 | ||||
| status |
?!SΣ | 1..1 | code | registered ｜ preliminary ｜ final ｜ amended + Binding: ObservationStatus (required): 檢驗檢查的狀態代碼；應填入所綁定值集中的其中一個代碼。 | ||||
| Slices for category |
S | 1..* | CodeableConceptTW | 概念（concept）－參照一個專門術語或只是純文字。 Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): 高層次的檢驗檢查分類；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。 | ||||
| category:twcore |
S | 0..* | CodeableConcept | Classification of type of observation Binding: 臺灣衛福部資訊處Observation Clinical Result類型值集 (required): 此slice綁定的值集之綁定強度雖為最高強度「要求使用(Requird)」，但因slice之特性，其不會限制僅能填此值集中的代碼，故在實作時也可使用其他值集的代碼。 | ||||
| code |
S | 1..1 | CodeableConceptTW | 概念（concept）－參照一個專門術語或只是純文字。 Binding: LOINCCodes (extensible): 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。 | ||||
| id |
0..1 | string | 唯一可識別ID，以供資料項目間相互參照。 | |||||
| extension |
0..* | Extension | 擴充的資料項目 Slice: Unordered, Open by value:url | |||||
| coding |
S | 0..* | CodingTW | 由專門術語系統（terminology system）定義的代碼 | ||||
| text |
SΣ | 0..1 | string | 概念的文字表示法 | ||||
| subject |
SΣ | 1..1 | Reference(TW Core Patient | TW Core Location | Group | Device) | 檢驗檢查有關的對象及（或）事物 | ||||
| focus |
Σ | 0..* | Reference(Resource) | 當檢驗檢查並非有關於與病人本身，檢驗檢查是關於什麼。 | ||||
| encounter |
SΣ | 0..1 | Reference(TW Core Encounter) | 檢驗檢查是哪一次就醫時執行的 | ||||
| effective[x] |
SΣC | 0..1 | 檢驗檢查執行日期或時間區間 tw-core-3: Datetime must be at least to day. | |||||
| effectiveDateTime |
dateTime S | |||||||
| effectivePeriod |
Period | |||||||
| effectiveTiming |
Timing | |||||||
| effectiveInstant |
instant | |||||||
| issued |
Σ | 0..1 | instant | 此版本檢驗檢查完成的日期或時間 | ||||
| performer |
Σ | 0..* | Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | TW Core PractitionerRole | TW Core CareTeam) | 誰負責這項檢驗檢查 | ||||
| value[x] |
SΣC | 0..1 | 檢驗檢查的實際結果 tw-core-5: SHALL use UCUM for coded quantity units. | |||||
| valueQuantity |
Quantity S | |||||||
| valueCodeableConcept |
CodeableConcept S | |||||||
| valueString |
string S | |||||||
| valueBoolean |
boolean | |||||||
| valueInteger |
integer | |||||||
| valueRange |
Range | |||||||
| valueRatio |
Ratio | |||||||
| valueSampledData |
SampledData | |||||||
| valueTime |
time | |||||||
| valueDateTime |
dateTime | |||||||
| valuePeriod |
Period | |||||||
| dataAbsentReason |
S | 0..1 | CodeableConceptTW | 缺少檢驗檢查結果的原因 Binding: DataAbsentReason (extensible): 代碼具體說明檢驗檢查結果缺少的原因；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。 | ||||
| interpretation |
0..* | CodeableConcept | 高、低、正常等 Binding: ObservationInterpretationCodes (extensible): 代碼指明檢驗檢查結果的解釋；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。 | |||||
| note |
0..* | Annotation | 關於此檢驗檢查之解說 | |||||
| bodySite |
0..1 | CodeableConcept | 接受檢驗檢查的身體部位。此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。 Binding: SNOMEDCTBodyStructures (example): 代碼說明解剖學位置，可能包含側邊；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。 | |||||
| method |
0..1 | CodeableConcept | 此檢驗檢查使用何種方法完成 Binding: ObservationMethods (example): 檢驗檢查的方法；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。 | |||||
| specimen |
0..1 | Reference(TW Core Specimen) | 此檢驗檢查的檢體 | |||||
| device |
0..1 | Reference(Device | DeviceMetric) | （測量）設備 | |||||
| referenceRange |
C | 0..* | BackboneElement | 解釋結果值的指引。
obs-3：必須至少有低、高或文字表述。 obs-3: Must have at least a low or a high or text | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| low |
C | 0..1 | SimpleQuantity | 參考範圍值的下限值，如果相關。 | ||||
| high |
C | 0..1 | SimpleQuantity | 參考範圍值的上限值，如果相關。 | ||||
| type |
0..1 | CodeableConcept | 參考範圍值的限定詞 Binding: ObservationReferenceRangeMeaningCodes (preferred): 用以表述參考範圍值之含意的代碼；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。 | |||||
| appliesTo |
0..* | CodeableConcept | 參考範圍值是用適用的對象或人口群 Binding: ObservationReferenceRangeAppliesToCodes (example): 用以指明參考範圍值適用的對象或人口群之代碼；可參考所綁定代碼表，但此代碼表只是針對這個欄位的一個可能值的示例，不預期也不鼓勵使用者一定要使用此代碼表的代碼代碼表中的代碼。 | |||||
| age |
0..1 | Range | 適用的年齡範圍值，如果相關。 | |||||
| text |
0..1 | string | 檢驗檢查中以文字表述的參考範圍值 | |||||
| hasMember |
Σ | 0..* | Reference(Observation | TW Core QuestionnaireResponse | MolecularSequence) | 屬於此組檢驗檢查的相關Resource | ||||
| derivedFrom |
Σ | 0..* | Reference(TW Core DocumentReference | TW Core ImagingStudy | TW Core Media | TW Core QuestionnaireResponse | Observation | MolecularSequence) | 檢驗檢查源自哪些相關測量 | ||||
| component |
Σ | 0..* | BackboneElement | 組成之（部分）檢驗檢查的檢驗結果 | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code |
Σ | 1..1 | CodeableConcept | 組成之檢驗檢查的型別（代碼／型別） Binding: LOINCCodes (example): 代碼指明檢驗檢查的名稱；可參考LOINCCodes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。 | ||||
| value[x] |
Σ | 0..1 | 組成之檢驗檢查的實際結果 | |||||
| valueQuantity |
Quantity | |||||||
| valueCodeableConcept |
CodeableConcept | |||||||
| valueString |
string | |||||||
| valueBoolean |
boolean | |||||||
| valueInteger |
integer | |||||||
| valueRange |
Range | |||||||
| valueRatio |
Ratio | |||||||
| valueSampledData |
SampledData | |||||||
| valueTime |
time | |||||||
| valueDateTime |
dateTime | |||||||
| valuePeriod |
Period | |||||||
| dataAbsentReason |
C | 0..1 | CodeableConcept | 為什麼缺少組成之檢驗檢查結果 Binding: DataAbsentReason (extensible): 代碼指明為什麼結果（Observation.value[x]）缺少；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。 | ||||
| interpretation |
0..* | CodeableConcept | 高、低、正常等。 Binding: ObservationInterpretationCodes (extensible): 用以指明檢驗檢查的解釋之代碼。應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。 | |||||
| referenceRange |
0..* | See referenceRange (Observation) | 解釋此組成之檢驗驗查的結果值之指引 | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Observation.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard
| ||||
| Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1from the FHIR Standard | ||||
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | ||||
| Observation.category:twcore | required | TWObservationClinicalResultCategoryhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/observation-clinical-result-categoryfrom this IG | ||||
| Observation.code | extensible | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard | ||||
| Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methodsfrom the FHIR Standard | ||||
| Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaningfrom the FHIR Standard | ||||
| Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliestofrom the FHIR Standard | ||||
| Observation.component.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
| tw-core-3 | error | Observation.effective[x] | Datetime must be at least to day. : $this is dateTime implies $this.toString().length() >= 10 | |
| tw-core-4 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present. : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
| tw-core-5 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org' |
This structure is derived from Observation
Summary
Mandatory: 2 elements
Must-Support: 9 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
以下概述了此Profile所需的RESTful FHIR互動功能。有關TW Core IG支援的RESTful互動功能的完整清單，請參閱TW Core Server能力聲明。
必須（SHALL） 支援透過查詢參數 patient 及 category 查詢所有Observation：
(如何透過reference查詢)
(如何透過token查詢)
GET [base]/Observation?patient={Type/}[id]&category=https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/category-code-tw|laboratory
例子：
(1) GET [base]/Observation?patient=Patient/pat-example&category=https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/category-code-tw|laboratory
必須（SHALL） 支援透過查詢參數 patient 及 code 查詢所有Observation：
(如何透過reference查詢)
(如何透過token查詢)
GET [base]/Observation?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}
例子：
(1) GET [base]/Observation?patient=Patient/pat-example&code=http://loinc.org|44974-4,http://loinc.org|44963-7,http://loinc.org|8601-7
必須（SHALL） 支援透過查詢參數 patient 、 category 及 date 查詢所有Observation：
(如何透過reference查詢)
(如何透過token查詢)
(如何透過date查詢)
GET [base]/Observation?patient={Type/}[id]&category=https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/category-code-tw|laboratory&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}
例子：
(1) GET [base]/Observation?patient=Patient/pat-example&category=https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/category-code-tw|laboratory&date=ge2020-01-01T00:00:00Z
建議應該（SHOULD） 支援透過查詢參數 patient 、 category 及 status 查詢所有Observation：
(如何透過reference查詢)
(如何透過token查詢)
GET [base]/Observation?patient={Type/}[id]&category=https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/category-code-tw|laboratoryh&status={system|}[code]{,{system|}[code],...}
例子：
(1) GET [base]/Observation?patient=Patient/pat-example&category=https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/category-code-tw|laboratory&status=final
建議應該（SHOULD） 支援透過查詢參數 patient 、 category 及 _lastUpdated 查詢所有Observation：
(如何透過reference查詢)
(如何透過token查詢)
(如何透過date查詢)
GET [base]/Observation?patient={Type/}[id]&category={system|}[code]&_lastUpdated={gt|lt|ge|le}[date]{&_lastUpdated={gt|lt|ge|le}[date]&...}
例子：
(1) GET [base]/Observation?patient=Patient/pat-example&category=https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/category-code-tw|laboratory&_lastUpdated=ge2024-01-01T00:00:00Z
支援透過查詢參數 patient 、 code 及 date 查詢所有Observation：
(如何透過reference查詢)
(如何透過token查詢)
(如何透過date查詢)
GET [base]/Observation?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}
例子：
(1) GET [base]/Observation?patient=Patient/pat-example&code=http://loinc.org|8867-4,http://loinc.org|85354-9,http://loinc.org|96607-7&date=ge2020-01-01T00:00:00Z