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: TWCoreObservationLaboratoryResult - Detailed Descriptions

Active as of 2024-11-07

Definitions for the Observation-laboratoryResult-twcore resource profile.

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

0. Observation
Definition

對病人、設備或其他對象進行的測量和簡單判定。

Short檢驗檢查,測量及簡單的判定。
2. Observation.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Observation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. Observation.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Observation Resource的metadata
6. Observation.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. Observation.language
Definition

編寫此resource的語言

Short用以表述Observation 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. Observation.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。

ShortObservation 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. Observation.identifier
Definition

此檢驗檢查的唯一識別碼

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

允許對檢驗檢查結果進行區分和參照

14. Observation.basedOn
Definition

依據的計劃、提議或醫令或其部分要求進行檢驗檢查。例如:一個MedicationRequest可能要求給病人藥之前要先進行實驗室檢查。

Short依據的照護計畫/提議/醫令
Requirements

允許授權追踪檢驗檢查事件並追踪提議/建議是否有落實

16. Observation.partOf
Definition

此特定的檢驗檢查(Observation)是一個更大事件中的一個組成或步驟。例如:一項處置裡的一項檢驗檢查。

Short此檢驗檢查是哪個參照事件的一部分
Comments

使用encounter將一個檢驗檢查(Observation)與一個就醫(Encounter)連結起來。關於參照另一個Observation的作法,請參閱下面的Notes小節。

18. Observation.status
Definition

結果值的狀態

Shortregistered | preliminary | final | amended +
Comments

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

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

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。

Requirements

需要追踪單個結果狀態,有些結果在整個報告確定之前就已經確定了。

20. Observation.category
Definition

可以正式參照一個專門術語或本體論來定義一個概念,或者也可以文字表述此概念。

Short概念(concept)-參照一個專門術語或只是純文字。
Comments

並非所有的專門術語使用都符合這個一般模式。在某些情況下,資料模型不應該使用CodeableConcept而應直接使用Coding,並提供他們自己的結構來管理text、codings、translation、資料項目之間的關係、以及先組合配對/前組合式(pre-coordination)和後組合配對/後組合式(post-coordination)。

BindingThe codes SHOULD be taken from ObservationCategoryCodes
(preferred to http://hl7.org/fhir/ValueSet/observation-category)

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。

Requirements

用於篩選取得及顯示之檢驗檢查

22. Observation.category:twcore
Slice Nametwcore
Control1..1
Pattern Value{
  "coding" : [{
    "system" : "http://terminology.hl7.org/CodeSystem/observation-category",
    "code" : "laboratory"
  }]
}
24. Observation.code
Definition

可以透過正式參照一個專門術語或本體論來定義一個概念,或者也可以文字表述此概念。

Short概念(concept)-參照一個專門術語或只是純文字。
Comments

並非所有的專門術語使用都符合這個一般模式。在某些情況下,資料模型不應該使用CodeableConcept而應直接使用Coding,並提供他們自己的結構來管理text、codings、translation、資料項目之間的關係、以及先組合配對/前組合式(pre-coordination)和後組合配對/後組合式(post-coordination)。

BindingUnless not suitable, these codes SHALL be taken from LOINCCodes
(extensible to http://hl7.org/fhir/ValueSet/observation-codes)

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

Requirements

知道正在進行的是哪種檢驗檢查是理解檢驗檢查的關鍵

26. Observation.code.coding
Definition

由專門術語系統(terminology system)所定義之代碼的參照。

Comments

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

Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

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

    應填入所綁定值集中的其中一個代碼。

    Must Supporttrue
    30. Observation.code.coding:LOINCObservationCode.system
    Definition

    定義代碼中符號意義的代碼系統識別。

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

    應填入所綁定值集中的其中一個代碼。

    Must Supporttrue
    36. Observation.code.coding:TWLaboratoryCategory.system
    Definition

    定義代碼中符號意義的代碼系統識別。

    Control1..?
    Pattern Valuehttps://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-service-payment-tw
    38. Observation.code.coding:TWLaboratoryCategory.code
    Control1..?
    40. Observation.subject
    Definition

    此檢驗檢查是關於一位病人、一群病人、地點、或設備。如果檢驗檢查的實際焦點與對象(或其樣本、其部分或其區域)不同,則焦點資料項目或代碼本身會具體說明檢驗檢查的實際焦點。

    Short檢驗檢查有關的對象及(或)事物
    Comments

    人們期望這個資料項目的cardinality為1...1。唯一可能缺少對象的情況是當檢驗檢查是由一個不認識病人的設備進行的。在這種情況下,應透過一些情境/通道對應(context/channel matching)技術將檢驗檢查與病人對應,此時,應更新檢驗檢查資訊。

    TypeReference(TW Core Patient)
    Requirements

    如果你不知道他們是誰或關於什麼,檢驗檢查不會有值。

    42. Observation.focus
    Definition

    檢驗檢查的實際焦點,當它不是記錄病人時,代表是與病人有關的事物或人,如配偶、父母、胎兒或捐贈者。例如:母親的記錄中有關胎兒檢驗檢查。檢驗檢查的焦點也可以是現有的狀況、疾病或問題(condition)、介入(intervention)、此對象的飲食、對此對象的另一項檢驗檢查,或身體結構像是腫瘤或植入裝置。有一個案例是使用Observation Resource來取得母親是否已接受更換她的小孩的氣管插管訓練之資訊,在這個例子中,孩子是此記錄的病人,而母親是focus。

    Short當檢驗檢查並非有關於與病人本身,檢驗檢查是關於什麼。
    Comments

    通常檢驗檢查的對象是一位病人或一群病人、地點或設備,檢驗檢查對象與直接測量內容之間的區別在observation.code已具體說明(例如: 「血糖」),不需要使用這個資料項目(focus)單獨表示。如果需要參照檢體,則使用specimen,如果需要一個代碼而不是一個resource,則使用bodysite來表示bodysites或標準擴充focusCode。

    44. Observation.encounter
    Definition

    執行檢驗檢查的健康照護事件(例如:病人及健康照護提供人員的互動)

    Short檢驗檢查是哪一次就醫時執行的
    Comments

    這通常指檢驗檢查發生於哪次就醫,但有些檢驗檢查可能是在就醫前或就醫後發生,但仍與就醫的情境有關(如入院前的實驗室檢驗檢查)。

    Requirements

    對於某些檢驗檢查來說,知道某個檢驗檢查和某個特定的就醫事件之間的連結可能很重要。

    46. Observation.effective[x]
    Definition

    宣告檢驗檢查值的產出時間或時間區段是真的。對於生物學研究對象—例如病人—這通常被稱為「生理相關時間」。這通常是處置的時間或採樣的時間,但很多時候不知道日期或時間的來源,只知道日期或時間本身。

    Short檢驗檢查執行日期或時間區間
    Comments

    除非這是一份檢驗檢查的歷史報告,否則至少應該有一個日期。為了記錄不精確或「模煳」的時間(例如:測量「早餐後 」血糖),使用Timing datatype以允許測量能與常規生活事件連結。

    Control1..?
    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
    Requirements

    知道一項檢驗檢查何時被認為是真的,對其相關性和確定趨勢都很重要。

    48. Observation.issued
    Definition

    此版本的檢驗檢查資訊可供健康照護提供人員取得的日期和時間,通常是在結果被審查與核實之後。

    Short此版本檢驗檢查完成的日期或時間
    Comments

    對於不需要審查和核實的檢驗檢查值,發佈日期時間可能與resource本身的最後更新日期時間相同。對於需要對某些更新進行審查和核實的檢驗檢查,若為非臨床上的重要更新則不需要對新版本進行再次審查和驗證,所以發佈日期時間可能與resource本身的最後更新日期時間不一樣。

    50. Observation.performer
    Definition

    誰負責宣告檢驗檢查結果值為「真的」

    Short誰負責這項檢驗檢查
    Must Supporttrue
    Requirements

    可以對此檢驗檢查有一定程度的信任,並指出後續問題的方向。

    52. Observation.value[x]
    Definition

    如果此資訊有一個簡單的值,則將其作為此項檢驗檢查的結果。

    Short檢驗檢查的實際結果
    Comments

    一項檢驗檢查可能有:(1)單一值、(2)一個值及一組相關或組成之檢驗檢查的多個值、或者(3)只有一組相關或組成之檢驗檢查的多個值。如果有一個值,這個資料項目的datatype應該由Observation.code決定。如果這個資料項目是編碼或者如果與Observation.code相關的type定義一個編碼值,那麼將使用只有文字表述的CodeableConcept來代替字串。若需要更多的說明,請參閱下面Notes小節。

    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
    Requirements

    通常一項檢驗檢查就會有一個值,雖然若它有錯誤或者它代表一組檢驗檢查可能不會有值。

    54. Observation.dataAbsentReason
    Definition

    提供資料項目Observation.value[x]中的預期值缺少的原因

    Short缺少檢驗檢查結果的原因
    Comments

    空值(Null)或例外值可以在FHIR Observations中以兩種方式表示,一種方法是簡單地將它們含括在值集中,並在值中表示例外。例如:血清檢測的測量值可以是「檢測到」、「未檢測到」、「不確定」或「檢測未完成」。

    另一種方法是使用資料項目value呈現實際檢驗檢查值,並使用資料項目dataAbsentReason來明確記錄例外值。例如:當測量沒有完成,可使用dataAbsentReason代碼「error」。請注意,只有在有值的情況下,才可以報告檢驗檢查。例如:只有在>0的情況下才可能報告細胞計數的差值。由於有這些選項,所以需要有使用案例協議(use-case agreements)來解釋一般檢驗檢查的例外值。

    BindingUnless not suitable, these codes SHALL be taken from DataAbsentReason
    (extensible to http://hl7.org/fhir/ValueSet/data-absent-reason)

    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。

    Requirements

    對於許多結果,必須處理測量中的異常值。

    56. Observation.interpretation
    Definition

    對一項檢驗檢查值的分類評估,例如:高、低、正常。

    Short高、低、正常等
    Comments

    歷史上用於實驗室結果【被稱為 「異常標記(abnormal flag)」】,它的使用延伸到其他與編碼解釋有關的使用情況中。通常報告為一個或多個簡單的緊密碼(compact code,一種可以解譯且具有最小平均字長的唯一資料代碼),這個資料項目經常被放置在報告和流程表的結果值的旁邊,以表示結果的意義或正常狀態。

    BindingUnless not suitable, these codes SHALL be taken from ObservationInterpretationCodes
    (extensible to http://hl7.org/fhir/ValueSet/observation-interpretation)

    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。

    TypeCodeableConcept(TW CodeableConcept)
    Requirements

    對於某些結果,特別是數值結果,需有一個解釋以便完全理解結果之意義。

    58. Observation.note
    Definition

    關於檢驗檢查或結果的解說

    Short關於此檢驗檢查之解說
    Comments

    可包括關於檢驗檢查的一般陳述,或關於重要的、非預期的或不可靠的結果值的陳述,或與資料項目interpretation有關的來源資訊。

    Requirements

    需能提供純文字表述的附加資訊

    60. Observation.bodySite
    Definition

    表示在檢驗檢查對象身上進行檢驗檢查的部位(即目標部位)

    Short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。
    Comments

    只有在Observation.code中的代碼未隱含時才會使用。在許多系統中,這可能被表示為一個相關的檢驗檢查,而不是一個行內的組成之檢驗檢查(inline component)。

    如果使用案例(use-case)要求將BodySite作為一個單獨的resource來處理(例如:單獨指明和追踪),那麼就使用標準的資料項目擴充方式來擴充bodySite。

    BindingUnless not suitable, these codes SHALL be taken from SNOMEDCTBodyStructures
    (extensible to http://hl7.org/fhir/ValueSet/body-site)

    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。

    TypeCodeableConcept(TW CodeableConcept)
    62. Observation.method
    Definition

    指明用於執行檢驗檢查的機制

    Short此檢驗檢查使用何種方法完成
    Comments

    只有在Observation.code中的代碼未隱含此資料項目概念時才會使用。

    BindingUnless not suitable, these codes SHALL be taken from ObservationMethods
    (extensible to http://hl7.org/fhir/ValueSet/observation-methods)

    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。

    TypeCodeableConcept(TW CodeableConcept)
    Requirements

    在某些情況下,方法會影響結果,因此用於確認結果是否可以比較或確認結果的顯著性(significance)。

    64. Observation.specimen
    Definition

    進行這項檢驗檢查時使用的檢體

    Short此檢驗檢查的檢體
    Comments

    只有在Observation.code中的代碼未隱含此資料項目概念時才會使用。 檢驗檢查不是針對檢體本身進行,而是針對對象,但在很多情況下是透過檢體的方式進行檢驗檢查。請注意,雖然經常涉及到檢體,但並不總是明確地對其進行追踪和報告。還要注意的是Observation resources可在明確追踪檢體的情境下使用(例如:Diagnostic Report)。

    66. Observation.device
    Definition

    用於產生檢驗檢查資料的設備

    Short(測量)設備
    Comments

    請注意,這不是用來表示結果傳輸的設備,例如:閘道器(gateway)等可在相關情況下使用 Provenance resource進行記錄。

    68. Observation.referenceRange
    Definition

    指導如何透過與正常或建議範圍值的比較來解釋此值。多個參考範圍值以「OR」解釋。換句話說,為了代表兩個不同的目標人群,將使用兩個referenceRange資料項目。

    Short解釋結果值的指引。 obs-3:必須至少有低、高或文字表述。
    Comments

    大多數檢驗檢查只有一個通用的參考範圍值。系統 可能可以(MAY) 選擇限制只提供病人的相關參考範圍值(例如:具體的病人年齡、性別、體重和其他因素),但這可能是不可能的或也不合適。只要提供了一個以上的參考範圍值,就 建議應該(SHOULD) 提供不同年齡的參考範圍值差異。

    Requirements

    知道什麼值被認為是「正常的」,可以幫助評估某一特定結果的意義。需要能夠為不同的情境提供多個參考範圍值。

    70. Observation.referenceRange.low
    Definition

    參考範圍值的下限值。參考範圍值endpoint的下限值包含在此值中(例如:參考範圍值是>=5 - <=9)。如果省略下限值,則被認為是沒有意義的(例如:參考範圍值是<=2.3)。

    Short參考範圍值的下限值,如果相關。
    72. Observation.referenceRange.high
    Definition

    參考範圍值的下限值。參考範圍值endpoint的下限值包含在此值中(例如:參考範圍值是>=5 - <=9)。如果省略下限值,則被認為是沒有意義的(例如:參考範圍值是<=2.3)。

    Short參考範圍值的上限值,如果相關。
    74. Observation.referenceRange.type
    Definition

    代碼表明適用的目標人群,例如:正常值或治療範圍值。

    Short參考範圍值的限定詞
    Comments

    如果有一個以上的範圍值,此資料項目 建議應該(SHOULD) 填寫。如果這個資料項目不存在,則假定是正常範圍值。

    BindingThe codes SHOULD be taken from ObservationReferenceRangeMeaningCodes
    (preferred to http://hl7.org/fhir/ValueSet/referencerange-meaning)

    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。

    TypeCodeableConcept(TW CodeableConcept)
    Requirements

    需要能夠說出這是什麼樣的參考範圍值:正常的、建議的、治療的等,以便正確解釋。

    76. Observation.referenceRange.appliesTo
    Definition

    代碼表明此參考範圍值所適用的目標人群,例如:一個參考範圍值可能是一般人群或特定的性別或種族。多個適用對象需以「AND」解釋目標人群。例如:為了表示一個非裔美國人女性的目標人群,將同時使用女性的代碼和非裔美國人的代碼。

    Short參考範圍值是用適用的對象或人口群
    Comments

    如果有一個以上的範圍值,此資料項目 建議應該(SHOULD) 填寫。如果這個資料項目不存在,則假定是正常範圍值。

    BindingFor example codes, see ObservationReferenceRangeAppliesToCodes
    (example to http://hl7.org/fhir/ValueSet/referencerange-appliesto)

    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。

    TypeCodeableConcept(TW CodeableConcept)
    Requirements

    需要能夠指明目標人群以進行適當的解釋。

    78. Observation.referenceRange.age
    Definition

    此參考範圍值適用的年齡,如果意思是說足月時的週數,這就是指新生兒年齡。

    Short適用的年齡範圍值,如果相關。
    Requirements

    有些分析隨著年齡的增長變化很大

    80. Observation.referenceRange.text
    Definition

    檢驗檢查中以文字表述的參考範圍值,可在不適合以定量範圍值呈現某項檢驗檢查時使用。例如:「陰性」的參照值或 「正常」的清單/列表。

    Short檢驗檢查中以文字表述的參考範圍值
    82. Observation.hasMember
    Definition

    這項檢驗檢查是一組檢驗檢查,例如:一個套組(battery)、一個檢驗套組(panel)或一組生命徵象測量,其組成的檢驗檢查為此資料項目的目標resource。

    Short屬於此組檢驗檢查的相關Resource
    Comments

    使用這個資料項目時,一項檢驗檢查通常會有一個值或者一組相關的resources,儘管在某些情況下兩者都可能存在。有關討論如何將Observations組合在一起的方法,請參閱下面的Notes小節。請注意,系統可能針對問卷調查的結果( QuestionnaireResponse)計算成一個最終的分數,並將這個分數表示為一個Observation。

    TypeReference(TW Core Observation Laboratory Result, TW Core QuestionnaireResponse, MolecularSequence)
    84. Observation.derivedFrom
    Definition

    目標resource為一種測量,此檢驗檢查就是從那個測量中得出。例如:陰離子間隙(an anion gap)或胎兒的測量值是從超音波影像計算而得。

    Short檢驗檢查源自哪些相關測量
    Comments

    在這個資料項目中列出可以代表臨床檢檢查和其他測量的所有參照選項,可能是衍生值的來源。最常見參照另一個Observation,關於Observations如何組合在一起的討論,請參閱下面的Notes小節。

    TypeReference(TW Core DocumentReference, TW Core ImagingStudy, TW Core Media, TW Core QuestionnaireResponse, TW Core Observation Laboratory Result, MolecularSequence)
    86. Observation.component
    Definition

    有有些檢驗檢查有多個組成之檢驗檢查,這些組成之檢驗檢查被表達為具有相同屬性的獨立的代碼值對(code value pair)。例子包括血壓測量的收縮壓和舒張壓即為組成之檢驗檢查(component observations),以及遺傳學檢驗檢查的多個組成之檢驗檢查。

    Short組成之(部分)檢驗檢查的檢驗結果
    Comments

    有關如何組合Observations的方法討論,請參閱下面的Notes小節。

    Must Supporttrue
    Requirements

    組成之檢驗檢查在Obsrvation resource中與主要檢驗檢查共享相同的屬性,並且總是被視為單個檢驗檢查的一部分(它們是不可分離的)。然而,主要檢驗檢查的參考範圍值並不被組成之檢驗檢查所繼承,在適當的時候需給予每項組成之檢驗檢查參考範圍值。

    88. Observation.component.code
    Definition

    描述所觀察到的情況,有時這被稱為檢驗檢查「代碼」。

    Short組成之檢驗檢查的型別(代碼/型別)
    Comments

    所有的code-value和component.code-component.value都需要考慮到,以正確理解檢驗檢查的意義。

    BindingFor example codes, see LOINC實驗室檢驗檢查值集
    (example to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-observation-code)

    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。

    TypeCodeableConcept(TW CodeableConcept)
    Must Supporttrue
    Requirements

    知道正在進行的是哪種檢驗檢查是理解檢驗檢查的關鍵

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

      應填入所綁定值集中的其中一個代碼。

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

      應填入所綁定值集中的其中一個代碼。

      Must Supporttrue
      100. Observation.component.code.coding:TWLaboratoryCategory.system
      Control1..?
      Must Supporttrue
      Pattern Valuehttps://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-service-payment-tw
      102. Observation.component.code.coding:TWLaboratoryCategory.code
      Control1..?
      Must Supporttrue
      104. Observation.component.value[x]
      Definition

      如果資訊中帶有一個值(simple value)則其可作為檢驗檢查的結果。

      Short組成之檢驗檢查的實際結果
      Comments

      一項檢驗檢查可能有一個值(如Apgar評分)和組成之檢驗檢查值(Apgar評分所來自多項檢驗檢查)。如果有一個值,這個資料項目的datatype應該由Observation.code決定。如果這個資料項目是編碼或者如果與Observation.code相關的type定義一個編碼值,那麼將使用只有文字表述的CodeableConcept來代替字串。若需要更多的說明,請參閱下面Notes小節。

      [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
      Must Supporttrue
      Requirements

      通常一項檢驗檢查就會有一個值,雖然若它有錯誤或者它代表一組檢驗檢查可能不會有值。

      106. Observation.component.dataAbsentReason
      Definition

      提供資料項目Observation.component.value[x]中的預期值缺少的原因

      Short為什麼缺少組成之檢驗檢查結果
      Comments

      空值(Null)或例外值可以在FHIR Observations中以兩種方式表示,一種方法是簡單地將它們含括在值集中,並在值中表示例外。例如:血清檢測的測量值可以是「檢測到」、「未檢測到」、「不確定」或「檢測未完成」。

      另一種方法是使用資料項目value呈現實際檢驗檢查值,並使用資料項目dataAbsentReason來明確記錄例外值。例如:當測量沒有完成,可使用dataAbsentReason代碼「error」。請注意,只有在有值的情況下,才可以報告檢驗檢查。例如:只有在>0的情況下才可能報告細胞計數的差值。由於有這些選項,所以需要有使用案例協議(use-case agreements)來解釋一般檢驗檢查的例外值。

      BindingUnless not suitable, these codes SHALL be taken from DataAbsentReason
      (extensible to http://hl7.org/fhir/ValueSet/data-absent-reason)

      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。

      TypeCodeableConcept(TW CodeableConcept)
      Requirements

      對於許多結果,必須處理測量中的異常值。

      108. Observation.component.interpretation
      Definition

      對一項檢驗檢查值的分類評估,例如:高、低、正常。

      Short高、低、正常等。
      Comments

      歷史上用於實驗室結果【被稱為 「異常標記(abnormal flag)」】,它的使用延伸到其他與編碼解釋有關的使用情況中。通常報告為一個或多個簡單的緊密碼(compact code,一種可以解譯且具有最小平均字長的唯一資料代碼),這個資料項目經常被放置在報告和流程表的結果值的旁邊,以表示結果的意義或正常狀態。

      BindingUnless not suitable, these codes SHALL be taken from ObservationInterpretationCodes
      (extensible to http://hl7.org/fhir/ValueSet/observation-interpretation)

      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。

      TypeCodeableConcept(TW CodeableConcept)
      Requirements

      對於某些結果,特別是數值結果,需有一個解釋以便完全理解結果之意義。

      110. Observation.component.referenceRange
      Definition

      關於如何透過與正常值或建議範圍值的比較來解釋此值

      Short解釋此組成之檢驗驗查的結果值之指引
      Comments

      大多數檢驗檢查只有一個通用的參考範圍值。系統 可能可以(MAY) 選擇限制只提供病人的相關參考範圍值(例如:具體的病人年齡、性別、體重和其他因素),但這可能是不可能的或也不合適。只要提供了一個以上的參考範圍值,就 建議應該(SHOULD) 提供不同年齡的參考範圍值差異。

      Requirements

      知道什麼值被認為是「正常的」,可以幫助評估某一特定結果的意義。需要能夠為不同的情境提供多個參考範圍值。

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

      0. Observation
      Definition

      對病人、設備或其他對象進行的測量和簡單判定。


      Measurements and simple assertions made about a patient, device or other subject.

      Short檢驗檢查,測量及簡單的判定。Measurements and simple assertions
      Comments

      Used for simple observations such as device measurements, laboratory atomic results, vital signs, height, weight, smoking status, comments, etc. Other resources are used to provide context for observations such as laboratory reports, etc.

      Control0..*
      Is Modifierfalse
      Summaryfalse
      Alternate NamesVital Signs, Measurement, Results, Tests
      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())
      obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present (dataAbsentReason.empty() or value.empty())
      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 (value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty())
      tw-core-4: 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()))
      obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present (dataAbsentReason.empty() or value.empty())
      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 (value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty())
      2. Observation.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Observation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. Observation.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Observation 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. Observation.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. Observation.language
      Definition

      編寫此resource的語言


      The base language in which the resource is written.

      Short用以表述Observation 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. Observation.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.

      ShortObservation 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. Observation.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. Observation.identifier
      Definition

      此檢驗檢查的唯一識別碼


      A unique identifier assigned to this observation.

      Short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。Business Identifier for observation
      NoteThis is a business identifier, not a resource identifier (see discussion)
      Control0..*
      TypeIdentifier
      Is Modifierfalse
      Summarytrue
      Requirements

      允許對檢驗檢查結果進行區分和參照


      Allows observations to be distinguished and referenced.

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

      依據的計劃、提議或醫令或其部分要求進行檢驗檢查。例如:一個MedicationRequest可能要求給病人藥之前要先進行實驗室檢查。


      A plan, proposal or order that is fulfilled in whole or in part by this event. For example, a MedicationRequest may require a patient to have laboratory test performed before it is dispensed.

      Short依據的照護計畫/提議/醫令Fulfills plan, proposal or order
      Control0..*
      TypeReference(TW Core CarePlan, DeviceRequest, ImmunizationRecommendation, TW Core MedicationRequest, NutritionOrder, TW Core ServiceRequest, CarePlan, MedicationRequest, ServiceRequest)
      Is Modifierfalse
      Summarytrue
      Requirements

      允許授權追踪檢驗檢查事件並追踪提議/建議是否有落實


      Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon.

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

      此特定的檢驗檢查(Observation)是一個更大事件中的一個組成或步驟。例如:一項處置裡的一項檢驗檢查。


      A larger event of which this particular Observation is a component or step. For example, an observation as part of a procedure.

      Short此檢驗檢查是哪個參照事件的一部分Part of referenced event
      Comments

      使用encounter將一個檢驗檢查(Observation)與一個就醫(Encounter)連結起來。關於參照另一個Observation的作法,請參閱下面的Notes小節。


      To link an Observation to an Encounter use encounter. See the Notes below for guidance on referencing another Observation.

      Control0..*
      TypeReference(MedicationAdministration, TW Core MedicationDispense, TW Core MedicationStatement, TW Core Procedure, TW Core Immunization, TW Core ImagingStudy, MedicationDispense, MedicationStatement, Procedure, Immunization, ImagingStudy)
      Is Modifierfalse
      Summarytrue
      Alternate NamesContainer
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      20. Observation.status
      Definition

      結果值的狀態


      The status of the result value.

      Shortregistered | preliminary | final | amended +registered | preliminary | final | amended +
      Comments

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


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

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

      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。


      Codes providing the status of an observation.

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

      需要追踪單個結果狀態,有些結果在整個報告確定之前就已經確定了。


      Need to track the status of individual results. Some results are finalized before the whole report is finalized.

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

      可以正式參照一個專門術語或本體論來定義一個概念,或者也可以文字表述此概念。


      A code that classifies the general type of observation being made.

      Short概念(concept)-參照一個專門術語或只是純文字。Classification of type of observation
      Comments

      並非所有的專門術語使用都符合這個一般模式。在某些情況下,資料模型不應該使用CodeableConcept而應直接使用Coding,並提供他們自己的結構來管理text、codings、translation、資料項目之間的關係、以及先組合配對/前組合式(pre-coordination)和後組合配對/後組合式(post-coordination)。


      In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set.

      Control10..*
      BindingThe codes SHOULD be taken from ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category
      (preferred to http://hl7.org/fhir/ValueSet/observation-category)

      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。


      Codes for high level observation categories.

      TypeCodeableConcept(TW CodeableConcept)
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Requirements

      用於篩選取得及顯示之檢驗檢查


      Used for filtering what observations are retrieved and displayed.

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

        A code that classifies the general type of observation being made.

        ShortClassification of type of observation
        Comments

        In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set.

        Control10..1*
        BindingThe codes SHALL be taken from The codes SHOULD be taken from 臺灣衛福部資訊處Observation Clinical Result類型值集http://hl7.org/fhir/ValueSet/observation-category
        (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/observation-clinical-result-category)

        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。


        Codes for high level observation categories.

        TypeCodeableConcept
        Is Modifierfalse
        Must Supporttrue
        Summaryfalse
        Requirements

        Used for filtering what observations are retrieved and displayed.

        Pattern Value{
          "coding" : [{
            "system" : "http://terminology.hl7.org/CodeSystem/observation-category",
            "code" : "laboratory"
          }]
        }
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        26. Observation.code
        Definition

        可以透過正式參照一個專門術語或本體論來定義一個概念,或者也可以文字表述此概念。


        Describes what was observed. Sometimes this is called the observation "name".

        Short概念(concept)-參照一個專門術語或只是純文字。Type of observation (code / type)
        Comments

        並非所有的專門術語使用都符合這個一般模式。在某些情況下,資料模型不應該使用CodeableConcept而應直接使用Coding,並提供他們自己的結構來管理text、codings、translation、資料項目之間的關係、以及先組合配對/前組合式(pre-coordination)和後組合配對/後組合式(post-coordination)。


        All code-value and, if present, component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.

        Control1..1
        This element is affected by the following invariants: ele-1
        BindingUnless not suitable, these codes SHALL be taken from For example codes, see LOINCCodeshttp://hl7.org/fhir/ValueSet/observation-codes
        (extensible to http://hl7.org/fhir/ValueSet/observation-codes)

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


        Codes identifying names of simple observations.

        TypeCodeableConcept(TW CodeableConcept)
        Is Modifierfalse
        Must Supporttrue
        Requirements

        知道正在進行的是哪種檢驗檢查是理解檢驗檢查的關鍵


        Knowing what kind of observation is being made is essential to understanding the observation.

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

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


        A reference to a code defined by a terminology system.

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

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


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

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

        允許使用者在不知道識別碼系統的情況下利用識別碼


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

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

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


          A reference to a code defined by a terminology system.

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

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


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

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

          應填入所綁定值集中的其中一個代碼。

          TypeCoding(TW Coding)
          Is Modifierfalse
          Must Supporttrue
          Requirements

          允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。


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

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

          定義代碼中符號意義的代碼系統識別。


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

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

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


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

          Control10..1
          Typeuri
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Must Supporttrue
          Summarytrue
          Requirements

          需要明確說明符號定義的來源


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

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

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


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

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

          需要參照系統中的一個特定代碼


          Need to refer to a particular code in the system.

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

          遵循系統的規則以呈現代碼含義的表示法


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

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

          需要能為不了解此系統的讀者呈現可讀的代碼含義


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

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

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


          A reference to a code defined by a terminology system.

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

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


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

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

          應填入所綁定值集中的其中一個代碼。

          TypeCoding(TW Coding)
          Is Modifierfalse
          Must Supporttrue
          Requirements

          允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。


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

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

          定義代碼中符號意義的代碼系統識別。


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

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

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


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

          Control10..1
          Typeuri
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Must Supporttrue
          Summarytrue
          Requirements

          需要明確說明符號定義的來源


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

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

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


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

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

          需要參照系統中的一個特定代碼


          Need to refer to a particular code in the system.

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

          遵循系統的規則以呈現代碼含義的表示法


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

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

          需要能為不了解此系統的讀者呈現可讀的代碼含義


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

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

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


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

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

          很多時候,此文字表述與其中一個代碼的顯示名稱相同。


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

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

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


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

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

          此檢驗檢查是關於一位病人、一群病人、地點、或設備。如果檢驗檢查的實際焦點與對象(或其樣本、其部分或其區域)不同,則焦點資料項目或代碼本身會具體說明檢驗檢查的實際焦點。


          The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the focus element or the code itself specifies the actual focus of the observation.

          Short檢驗檢查有關的對象及(或)事物Who and/or what the observation is about
          Comments

          人們期望這個資料項目的cardinality為1...1。唯一可能缺少對象的情況是當檢驗檢查是由一個不認識病人的設備進行的。在這種情況下,應透過一些情境/通道對應(context/channel matching)技術將檢驗檢查與病人對應,此時,應更新檢驗檢查資訊。


          One would expect this element to be a cardinality of 1..1. The only circumstance in which the subject can be missing is when the observation is made by a device that does not know the patient. In this case, the observation SHALL be matched to a patient through some context/channel matching technique, and at this point, the observation should be updated.

          Control10..1
          TypeReference(TW Core Patient, Patient, Group, Device, Location)
          Is Modifierfalse
          Must Supporttrue
          Summarytrue
          Requirements

          如果你不知道他們是誰或關於什麼,檢驗檢查不會有值。


          Observations have no value if you don't know who or what they're about.

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

          檢驗檢查的實際焦點,當它不是記錄病人時,代表是與病人有關的事物或人,如配偶、父母、胎兒或捐贈者。例如:母親的記錄中有關胎兒檢驗檢查。檢驗檢查的焦點也可以是現有的狀況、疾病或問題(condition)、介入(intervention)、此對象的飲食、對此對象的另一項檢驗檢查,或身體結構像是腫瘤或植入裝置。有一個案例是使用Observation Resource來取得母親是否已接受更換她的小孩的氣管插管訓練之資訊,在這個例子中,孩子是此記錄的病人,而母親是focus。


          The actual focus of an observation when it is not the patient of record representing something or someone associated with the patient such as a spouse, parent, fetus, or donor. For example, fetus observations in a mother's record. The focus of an observation could also be an existing condition, an intervention, the subject's diet, another observation of the subject, or a body structure such as tumor or implanted device. An example use case would be using the Observation resource to capture whether the mother is trained to change her child's tracheostomy tube. In this example, the child is the patient of record and the mother is the focus.

          Short當檢驗檢查並非有關於與病人本身,檢驗檢查是關於什麼。What the observation is about, when it is not about the subject of record
          Comments

          通常檢驗檢查的對象是一位病人或一群病人、地點或設備,檢驗檢查對象與直接測量內容之間的區別在observation.code已具體說明(例如: 「血糖」),不需要使用這個資料項目(focus)單獨表示。如果需要參照檢體,則使用specimen,如果需要一個代碼而不是一個resource,則使用bodysite來表示bodysites或標準擴充focusCode。


          Typically, an observation is made about the subject - a patient, or group of patients, location, or device - and the distinction between the subject and what is directly measured for an observation is specified in the observation code itself ( e.g., "Blood Glucose") and does not need to be represented separately using this element. Use specimen if a reference to a specimen is required. If a code is required instead of a resource use either bodysite for bodysites or the standard extension focusCode.

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

          執行檢驗檢查的健康照護事件(例如:病人及健康照護提供人員的互動)


          The healthcare event (e.g. a patient and healthcare provider interaction) during which this observation is made.

          Short檢驗檢查是哪一次就醫時執行的Healthcare event during which this observation is made
          Comments

          這通常指檢驗檢查發生於哪次就醫,但有些檢驗檢查可能是在就醫前或就醫後發生,但仍與就醫的情境有關(如入院前的實驗室檢驗檢查)。


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

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

          對於某些檢驗檢查來說,知道某個檢驗檢查和某個特定的就醫事件之間的連結可能很重要。


          For some observations it may be important to know the link between an observation and a particular encounter.

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

          宣告檢驗檢查值的產出時間或時間區段是真的。對於生物學研究對象—例如病人—這通常被稱為「生理相關時間」。這通常是處置的時間或採樣的時間,但很多時候不知道日期或時間的來源,只知道日期或時間本身。


          The time or time-period the observed value is asserted as being true. For biological subjects - e.g. human patients - this is usually called the "physiologically relevant time". This is usually either the time of the procedure or of specimen collection, but very often the source of the date/time is not known, only the date/time itself.

          Short檢驗檢查執行日期或時間區間Clinically relevant time/time-period for observation
          Comments

          除非這是一份檢驗檢查的歷史報告,否則至少應該有一個日期。為了記錄不精確或「模煳」的時間(例如:測量「早餐後 」血糖),使用Timing datatype以允許測量能與常規生活事件連結。


          At least a date should be present unless this observation is a historical report. For recording imprecise or "fuzzy" times (For example, a blood glucose measurement taken "after breakfast") use the Timing datatype which allow the measurement to be tied to regular life events.

          Control10..1
          TypeChoice of: dateTime, Period, Timing, instant
          [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Must Supporttrue
          Must Support TypesdateTime
          Summarytrue
          Requirements

          知道一項檢驗檢查何時被認為是真的,對其相關性和確定趨勢都很重要。


          Knowing when an observation was deemed true is important to its relevance as well as determining trends.

          Alternate NamesOccurrence
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          tw-core-3: Datetime must be at least to day. ($this is dateTime implies $this.toString().length() >= 10)
          56. Observation.issued
          Definition

          此版本的檢驗檢查資訊可供健康照護提供人員取得的日期和時間,通常是在結果被審查與核實之後。


          The date and time this version of the observation was made available to providers, typically after the results have been reviewed and verified.

          Short此版本檢驗檢查完成的日期或時間Date/Time this version was made available
          Comments

          對於不需要審查和核實的檢驗檢查值,發佈日期時間可能與resource本身的最後更新日期時間相同。對於需要對某些更新進行審查和核實的檢驗檢查,若為非臨床上的重要更新則不需要對新版本進行再次審查和驗證,所以發佈日期時間可能與resource本身的最後更新日期時間不一樣。


          For Observations that don’t require review and verification, it may be the same as the lastUpdated time of the resource itself. For Observations that do require review and verification for certain updates, it might not be the same as the lastUpdated time of the resource itself due to a non-clinically significant update that doesn’t require the new version to be reviewed and verified again.

          Control0..1
          Typeinstant
          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()))
          58. Observation.performer
          Definition

          誰負責宣告檢驗檢查結果值為「真的」


          Who was responsible for asserting the observed value as "true".

          Short誰負責這項檢驗檢查Who is responsible for the observation
          Control0..*
          TypeReference(TW Core Practitioner, TW Core Organization, TW Core Patient, TW Core PractitionerRole, TW Core CareTeam, Practitioner, PractitionerRole, Organization, CareTeam, Patient, RelatedPerson)
          Is Modifierfalse
          Must Supporttrue
          Must Support TypesNo must-support rules about the choice of types/profiles
          Summarytrue
          Requirements

          可以對此檢驗檢查有一定程度的信任,並指出後續問題的方向。


          May give a degree of confidence in the observation and also indicates where follow-up questions should be directed.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          60. Observation.value[x]
          Definition

          如果此資訊有一個簡單的值,則將其作為此項檢驗檢查的結果。


          The information determined as a result of making the observation, if the information has a simple value.

          Short檢驗檢查的實際結果Actual result
          Comments

          一項檢驗檢查可能有:(1)單一值、(2)一個值及一組相關或組成之檢驗檢查的多個值、或者(3)只有一組相關或組成之檢驗檢查的多個值。如果有一個值,這個資料項目的datatype應該由Observation.code決定。如果這個資料項目是編碼或者如果與Observation.code相關的type定義一個編碼值,那麼將使用只有文字表述的CodeableConcept來代替字串。若需要更多的說明,請參閱下面Notes小節。


          An observation may have; 1) a single value here, 2) both a value and a set of related or component values, or 3) only a set of related or component values. If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the Notes section below.

          Control0..1
          This element is affected by the following invariants: obs-7
          TypeChoice of: Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period
          [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Must Supporttrue
          Must Support TypesChoice of: Quantity, CodeableConcept, string
          Summarytrue
          Requirements

          通常一項檢驗檢查就會有一個值,雖然若它有錯誤或者它代表一組檢驗檢查可能不會有值。


          An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          tw-core-5: SHALL use UCUM for coded quantity units. (ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org')
          62. Observation.dataAbsentReason
          Definition

          提供資料項目Observation.value[x]中的預期值缺少的原因


          Provides a reason why the expected value in the element Observation.value[x] is missing.

          Short缺少檢驗檢查結果的原因Why the result is missing
          Comments

          空值(Null)或例外值可以在FHIR Observations中以兩種方式表示,一種方法是簡單地將它們含括在值集中,並在值中表示例外。例如:血清檢測的測量值可以是「檢測到」、「未檢測到」、「不確定」或「檢測未完成」。

          另一種方法是使用資料項目value呈現實際檢驗檢查值,並使用資料項目dataAbsentReason來明確記錄例外值。例如:當測量沒有完成,可使用dataAbsentReason代碼「error」。請注意,只有在有值的情況下,才可以報告檢驗檢查。例如:只有在>0的情況下才可能報告細胞計數的差值。由於有這些選項,所以需要有使用案例協議(use-case agreements)來解釋一般檢驗檢查的例外值。


          Null or exceptional values can be represented two ways in FHIR Observations. One way is to simply include them in the value set and represent the exceptions in the value. For example, measurement values for a serology test could be "detected", "not detected", "inconclusive", or "specimen unsatisfactory".

          The alternate way is to use the value element for actual observations and use the explicit dataAbsentReason element to record exceptional values. For example, the dataAbsentReason code "error" could be used when the measurement was not completed. Note that an observation may only be reported if there are values to report. For example differential cell counts values may be reported only when > 0. Because of these options, use-case agreements are required to interpret general observations for null or exceptional values.

          Control0..1
          This element is affected by the following invariants: ele-1, obs-6
          BindingUnless not suitable, these codes SHALL be taken from DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason
          (extensible to http://hl7.org/fhir/ValueSet/data-absent-reason)

          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。


          Codes specifying why the result (Observation.value[x]) is missing.

          TypeCodeableConcept(TW CodeableConcept)
          Is Modifierfalse
          Must Supporttrue
          Requirements

          對於許多結果,必須處理測量中的異常值。


          For many results it is necessary to handle exceptional values in measurements.

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

          對一項檢驗檢查值的分類評估,例如:高、低、正常。


          A categorical assessment of an observation value. For example, high, low, normal.

          Short高、低、正常等High, low, normal, etc.
          Comments

          歷史上用於實驗室結果【被稱為 「異常標記(abnormal flag)」】,它的使用延伸到其他與編碼解釋有關的使用情況中。通常報告為一個或多個簡單的緊密碼(compact code,一種可以解譯且具有最小平均字長的唯一資料代碼),這個資料項目經常被放置在報告和流程表的結果值的旁邊,以表示結果的意義或正常狀態。


          Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result.

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

          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。


          Codes identifying interpretations of observations.

          TypeCodeableConcept(TW CodeableConcept)
          Is Modifierfalse
          Requirements

          對於某些結果,特別是數值結果,需有一個解釋以便完全理解結果之意義。


          For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result.

          Alternate NamesAbnormal Flag
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          66. Observation.note
          Definition

          關於檢驗檢查或結果的解說


          Comments about the observation or the results.

          Short關於此檢驗檢查之解說Comments about the observation
          Comments

          可包括關於檢驗檢查的一般陳述,或關於重要的、非預期的或不可靠的結果值的陳述,或與資料項目interpretation有關的來源資訊。


          May include general statements about the observation, or statements about significant, unexpected or unreliable results values, or information about its source when relevant to its interpretation.

          Control0..*
          TypeAnnotation
          Is Modifierfalse
          Summaryfalse
          Requirements

          需能提供純文字表述的附加資訊


          Need to be able to provide free text additional information.

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

          表示在檢驗檢查對象身上進行檢驗檢查的部位(即目標部位)


          Indicates the site on the subject's body where the observation was made (i.e. the target site).

          Short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。Observed body part
          Comments

          只有在Observation.code中的代碼未隱含時才會使用。在許多系統中,這可能被表示為一個相關的檢驗檢查,而不是一個行內的組成之檢驗檢查(inline component)。

          如果使用案例(use-case)要求將BodySite作為一個單獨的resource來處理(例如:單獨指明和追踪),那麼就使用標準的資料項目擴充方式來擴充bodySite。


          Only used if not implicit in code found in Observation.code. In many systems, this may be represented as a related observation instead of an inline component.

          If the use case requires BodySite to be handled as a separate resource (e.g. to identify and track separately) then use the standard extension bodySite.

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

          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。


          Codes describing anatomical locations. May include laterality.

          TypeCodeableConcept(TW CodeableConcept)
          Is Modifierfalse
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          70. Observation.method
          Definition

          指明用於執行檢驗檢查的機制


          Indicates the mechanism used to perform the observation.

          Short此檢驗檢查使用何種方法完成How it was done
          Comments

          只有在Observation.code中的代碼未隱含此資料項目概念時才會使用。


          Only used if not implicit in code for Observation.code.

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

          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。


          Methods for simple observations.

          TypeCodeableConcept(TW CodeableConcept)
          Is Modifierfalse
          Requirements

          在某些情況下,方法會影響結果,因此用於確認結果是否可以比較或確認結果的顯著性(significance)。


          In some cases, method can impact results and is thus used for determining whether results can be compared or determining significance of results.

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

          進行這項檢驗檢查時使用的檢體


          The specimen that was used when this observation was made.

          Short此檢驗檢查的檢體Specimen used for this observation
          Comments

          只有在Observation.code中的代碼未隱含此資料項目概念時才會使用。 檢驗檢查不是針對檢體本身進行,而是針對對象,但在很多情況下是透過檢體的方式進行檢驗檢查。請注意,雖然經常涉及到檢體,但並不總是明確地對其進行追踪和報告。還要注意的是Observation resources可在明確追踪檢體的情境下使用(例如:Diagnostic Report)。


          Should only be used if not implicit in code found in Observation.code. Observations are not made on specimens themselves; they are made on a subject, but in many cases by the means of a specimen. Note that although specimens are often involved, they are not always tracked and reported explicitly. Also note that observation resources may be used in contexts that track the specimen explicitly (e.g. Diagnostic Report).

          Control0..1
          TypeReference(TW Core Specimen, Specimen)
          Is Modifierfalse
          Summaryfalse
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          74. Observation.device
          Definition

          用於產生檢驗檢查資料的設備


          The device used to generate the observation data.

          Short(測量)設備(Measurement) Device
          Comments

          請注意,這不是用來表示結果傳輸的設備,例如:閘道器(gateway)等可在相關情況下使用 Provenance resource進行記錄。


          Note that this is not meant to represent a device involved in the transmission of the result, e.g., a gateway. Such devices may be documented using the Provenance resource where relevant.

          Control0..1
          TypeReference(Device, DeviceMetric)
          Is Modifierfalse
          Summaryfalse
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          76. Observation.referenceRange
          Definition

          指導如何透過與正常或建議範圍值的比較來解釋此值。多個參考範圍值以「OR」解釋。換句話說,為了代表兩個不同的目標人群,將使用兩個referenceRange資料項目。


          Guidance on how to interpret the value by comparison to a normal or recommended range. Multiple reference ranges are interpreted as an "OR". In other words, to represent two distinct target populations, two referenceRange elements would be used.

          Short解釋結果值的指引。 obs-3:必須至少有低、高或文字表述。Provides guide for interpretation
          Comments

          大多數檢驗檢查只有一個通用的參考範圍值。系統 可能可以(MAY) 選擇限制只提供病人的相關參考範圍值(例如:具體的病人年齡、性別、體重和其他因素),但這可能是不可能的或也不合適。只要提供了一個以上的參考範圍值,就 建議應該(SHOULD) 提供不同年齡的參考範圍值差異。


          Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this might not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties.

          Control0..*
          TypeBackboneElement
          Is Modifierfalse
          Summaryfalse
          Requirements

          知道什麼值被認為是「正常的」,可以幫助評估某一特定結果的意義。需要能夠為不同的情境提供多個參考範圍值。


          Knowing what values are considered "normal" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          obs-3: Must have at least a low or a high or text (low.exists() or high.exists() or text.exists())
          obs-3: Must have at least a low or a high or text (low.exists() or high.exists() or text.exists())
          78. Observation.referenceRange.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())
          80. Observation.referenceRange.low
          Definition

          參考範圍值的下限值。參考範圍值endpoint的下限值包含在此值中(例如:參考範圍值是>=5 - <=9)。如果省略下限值,則被認為是沒有意義的(例如:參考範圍值是<=2.3)。


          The value of the low bound of the reference range. The low bound of the reference range endpoint is inclusive of the value (e.g. reference range is >=5 - <=9). If the low bound is omitted, it is assumed to be meaningless (e.g. reference range is <=2.3).

          Short參考範圍值的下限值,如果相關。Low Range, if relevant
          Control0..1
          This element is affected by the following invariants: obs-3
          TypeQuantity(SimpleQuantity)
          Is Modifierfalse
          Summaryfalse
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          82. Observation.referenceRange.high
          Definition

          參考範圍值的下限值。參考範圍值endpoint的下限值包含在此值中(例如:參考範圍值是>=5 - <=9)。如果省略下限值,則被認為是沒有意義的(例如:參考範圍值是<=2.3)。


          The value of the high bound of the reference range. The high bound of the reference range endpoint is inclusive of the value (e.g. reference range is >=5 - <=9). If the high bound is omitted, it is assumed to be meaningless (e.g. reference range is >= 2.3).

          Short參考範圍值的上限值,如果相關。High Range, if relevant
          Control0..1
          This element is affected by the following invariants: obs-3
          TypeQuantity(SimpleQuantity)
          Is Modifierfalse
          Summaryfalse
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          84. Observation.referenceRange.type
          Definition

          代碼表明適用的目標人群,例如:正常值或治療範圍值。


          Codes to indicate the what part of the targeted reference population it applies to. For example, the normal or therapeutic range.

          Short參考範圍值的限定詞Reference range qualifier
          Comments

          如果有一個以上的範圍值,此資料項目 建議應該(SHOULD) 填寫。如果這個資料項目不存在,則假定是正常範圍值。


          This SHOULD be populated if there is more than one range. If this element is not present then the normal range is assumed.

          Control0..1
          This element is affected by the following invariants: ele-1
          BindingThe codes SHOULD be taken from ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaning
          (preferred to http://hl7.org/fhir/ValueSet/referencerange-meaning)

          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。


          Code for the meaning of a reference range.

          TypeCodeableConcept(TW CodeableConcept)
          Is Modifierfalse
          Requirements

          需要能夠說出這是什麼樣的參考範圍值:正常的、建議的、治療的等,以便正確解釋。


          Need to be able to say what kind of reference range this is - normal, recommended, therapeutic, etc., - for proper interpretation.

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

          代碼表明此參考範圍值所適用的目標人群,例如:一個參考範圍值可能是一般人群或特定的性別或種族。多個適用對象需以「AND」解釋目標人群。例如:為了表示一個非裔美國人女性的目標人群,將同時使用女性的代碼和非裔美國人的代碼。


          Codes to indicate the target population this reference range applies to. For example, a reference range may be based on the normal population or a particular sex or race. Multiple appliesTo are interpreted as an "AND" of the target populations. For example, to represent a target population of African American females, both a code of female and a code for African American would be used.

          Short參考範圍值是用適用的對象或人口群Reference range population
          Comments

          如果有一個以上的範圍值,此資料項目 建議應該(SHOULD) 填寫。如果這個資料項目不存在,則假定是正常範圍值。


          This SHOULD be populated if there is more than one range. If this element is not present then the normal population is assumed.

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

          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。


          Codes identifying the population the reference range applies to.

          TypeCodeableConcept(TW CodeableConcept)
          Is Modifierfalse
          Requirements

          需要能夠指明目標人群以進行適當的解釋。


          Need to be able to identify the target population for proper interpretation.

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

          此參考範圍值適用的年齡,如果意思是說足月時的週數,這就是指新生兒年齡。


          The age at which this reference range is applicable. This is a neonatal age (e.g. number of weeks at term) if the meaning says so.

          Short適用的年齡範圍值,如果相關。Applicable age range, if relevant
          Control0..1
          TypeRange
          Is Modifierfalse
          Summaryfalse
          Requirements

          有些分析隨著年齡的增長變化很大


          Some analytes vary greatly over age.

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

          檢驗檢查中以文字表述的參考範圍值,可在不適合以定量範圍值呈現某項檢驗檢查時使用。例如:「陰性」的參照值或 「正常」的清單/列表。


          Text based reference range in an observation which may be used when a quantitative range is not appropriate for an observation. An example would be a reference value of "Negative" or a list or table of "normals".

          Short檢驗檢查中以文字表述的參考範圍值Text based reference range in an observation
          Control0..1
          Typestring
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Summaryfalse
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          92. Observation.hasMember
          Definition

          這項檢驗檢查是一組檢驗檢查,例如:一個套組(battery)、一個檢驗套組(panel)或一組生命徵象測量,其組成的檢驗檢查為此資料項目的目標resource。


          This observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group.

          Short屬於此組檢驗檢查的相關ResourceRelated resource that belongs to the Observation group
          Comments

          使用這個資料項目時,一項檢驗檢查通常會有一個值或者一組相關的resources,儘管在某些情況下兩者都可能存在。有關討論如何將Observations組合在一起的方法,請參閱下面的Notes小節。請注意,系統可能針對問卷調查的結果( QuestionnaireResponse)計算成一個最終的分數,並將這個分數表示為一個Observation。


          When using this element, an observation will typically have either a value or a set of related resources, although both may be present in some cases. For a discussion on the ways Observations can assembled in groups together, see Notes below. Note that a system may calculate results from QuestionnaireResponse into a final score and represent the score as an Observation.

          Control0..*
          TypeReference(TW Core Observation Laboratory Result, TW Core QuestionnaireResponse, MolecularSequence, Observation, QuestionnaireResponse)
          Is Modifierfalse
          Summarytrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          94. Observation.derivedFrom
          Definition

          目標resource為一種測量,此檢驗檢查就是從那個測量中得出。例如:陰離子間隙(an anion gap)或胎兒的測量值是從超音波影像計算而得。


          The target resource that represents a measurement from which this observation value is derived. For example, a calculated anion gap or a fetal measurement based on an ultrasound image.

          Short檢驗檢查源自哪些相關測量Related measurements the observation is made from
          Comments

          在這個資料項目中列出可以代表臨床檢檢查和其他測量的所有參照選項,可能是衍生值的來源。最常見參照另一個Observation,關於Observations如何組合在一起的討論,請參閱下面的Notes小節。


          All the reference choices that are listed in this element can represent clinical observations and other measurements that may be the source for a derived value. The most common reference will be another Observation. For a discussion on the ways Observations can assembled in groups together, see Notes below.

          Control0..*
          TypeReference(TW Core DocumentReference, TW Core ImagingStudy, TW Core Media, TW Core QuestionnaireResponse, TW Core Observation Laboratory Result, MolecularSequence, DocumentReference, ImagingStudy, Media, QuestionnaireResponse, Observation)
          Is Modifierfalse
          Summarytrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          96. Observation.component
          Definition

          有有些檢驗檢查有多個組成之檢驗檢查,這些組成之檢驗檢查被表達為具有相同屬性的獨立的代碼值對(code value pair)。例子包括血壓測量的收縮壓和舒張壓即為組成之檢驗檢查(component observations),以及遺傳學檢驗檢查的多個組成之檢驗檢查。


          Some observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes. Examples include systolic and diastolic component observations for blood pressure measurement and multiple component observations for genetics observations.

          Short組成之(部分)檢驗檢查的檢驗結果Component results
          Comments

          有關如何組合Observations的方法討論,請參閱下面的Notes小節。


          For a discussion on the ways Observations can be assembled in groups together see Notes below.

          Control0..*
          TypeBackboneElement
          Is Modifierfalse
          Must Supporttrue
          Summarytrue
          Requirements

          組成之檢驗檢查在Obsrvation resource中與主要檢驗檢查共享相同的屬性,並且總是被視為單個檢驗檢查的一部分(它們是不可分離的)。然而,主要檢驗檢查的參考範圍值並不被組成之檢驗檢查所繼承,在適當的時候需給予每項組成之檢驗檢查參考範圍值。


          Component observations share the same attributes in the Observation resource as the primary observation and are always treated a part of a single observation (they are not separable). However, the reference range for the primary observation value is not inherited by the component values and is required when appropriate for each component observation.

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

          描述所觀察到的情況,有時這被稱為檢驗檢查「代碼」。


          Describes what was observed. Sometimes this is called the observation "code".

          Short組成之檢驗檢查的型別(代碼/型別)Type of component observation (code / type)
          Comments

          所有的code-value和component.code-component.value都需要考慮到,以正確理解檢驗檢查的意義。


          All code-value and component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.

          Control1..1
          This element is affected by the following invariants: ele-1
          BindingFor example codes, see LOINC實驗室檢驗檢查值集http://hl7.org/fhir/ValueSet/observation-codes
          (example to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-observation-code)

          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。


          Codes identifying names of simple observations.

          TypeCodeableConcept(TW CodeableConcept)
          Is Modifierfalse
          Must Supporttrue
          Requirements

          知道正在進行的是哪種檢驗檢查是理解檢驗檢查的關鍵


          Knowing what kind of observation is being made is essential to understanding the observation.

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

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


          A reference to a code defined by a terminology system.

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

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


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

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

          允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。


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

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

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


            A reference to a code defined by a terminology system.

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

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


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

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

            應填入所綁定值集中的其中一個代碼。

            TypeCoding(TW Coding)
            Is Modifierfalse
            Must Supporttrue
            Requirements

            允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。


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

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

            定義代碼中符號意義的代碼系統識別


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

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

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


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

            Control10..1
            Typeuri
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Must Supporttrue
            Summarytrue
            Requirements

            需要明確說明符號定義的來源


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

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

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


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

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

            需要參照系統中的一個特定代碼


            Need to refer to a particular code in the system.

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

            遵循系統的規則以呈現代碼含義的表示法


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

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

            需要能為不了解此系統的讀者呈現可讀的代碼含義


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

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

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


            A reference to a code defined by a terminology system.

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

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


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

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

            應填入所綁定值集中的其中一個代碼。

            TypeCoding(TW Coding)
            Is Modifierfalse
            Must Supporttrue
            Requirements

            允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。


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

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

            定義代碼中符號意義的代碼系統識別


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

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

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


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

            Control10..1
            Typeuri
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Must Supporttrue
            Summarytrue
            Requirements

            需要明確說明符號定義的來源


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

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

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


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

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

            需要參照系統中的一個特定代碼


            Need to refer to a particular code in the system.

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

            遵循系統的規則以呈現代碼含義的表示法


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

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

            需要能為不了解此系統的讀者呈現可讀的代碼含義


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

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

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


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

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

            很多時候,此文字表述與其中一個代碼的顯示名稱相同。


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

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

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


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

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            122. Observation.component.value[x]
            Definition

            如果資訊中帶有一個值(simple value)則其可作為檢驗檢查的結果。


            The information determined as a result of making the observation, if the information has a simple value.

            Short組成之檢驗檢查的實際結果Actual component result
            Comments

            一項檢驗檢查可能有一個值(如Apgar評分)和組成之檢驗檢查值(Apgar評分所來自多項檢驗檢查)。如果有一個值,這個資料項目的datatype應該由Observation.code決定。如果這個資料項目是編碼或者如果與Observation.code相關的type定義一個編碼值,那麼將使用只有文字表述的CodeableConcept來代替字串。若需要更多的說明,請參閱下面Notes小節。


            Used when observation has a set of component observations. An observation may have both a value (e.g. an Apgar score) and component observations (the observations from which the Apgar score was derived). If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the Notes section below.

            Control0..1
            TypeChoice of: Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period
            [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Must Supporttrue
            Must Support TypesNo must-support rules about the choice of types/profiles
            Summarytrue
            Requirements

            通常一項檢驗檢查就會有一個值,雖然若它有錯誤或者它代表一組檢驗檢查可能不會有值。


            An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations.

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

            提供資料項目Observation.component.value[x]中的預期值缺少的原因


            Provides a reason why the expected value in the element Observation.component.value[x] is missing.

            Short為什麼缺少組成之檢驗檢查結果Why the component result is missing
            Comments

            空值(Null)或例外值可以在FHIR Observations中以兩種方式表示,一種方法是簡單地將它們含括在值集中,並在值中表示例外。例如:血清檢測的測量值可以是「檢測到」、「未檢測到」、「不確定」或「檢測未完成」。

            另一種方法是使用資料項目value呈現實際檢驗檢查值,並使用資料項目dataAbsentReason來明確記錄例外值。例如:當測量沒有完成,可使用dataAbsentReason代碼「error」。請注意,只有在有值的情況下,才可以報告檢驗檢查。例如:只有在>0的情況下才可能報告細胞計數的差值。由於有這些選項,所以需要有使用案例協議(use-case agreements)來解釋一般檢驗檢查的例外值。


            "Null" or exceptional values can be represented two ways in FHIR Observations. One way is to simply include them in the value set and represent the exceptions in the value. For example, measurement values for a serology test could be "detected", "not detected", "inconclusive", or "test not done".

            The alternate way is to use the value element for actual observations and use the explicit dataAbsentReason element to record exceptional values. For example, the dataAbsentReason code "error" could be used when the measurement was not completed. Because of these options, use-case agreements are required to interpret general observations for exceptional values.

            Control0..1
            This element is affected by the following invariants: ele-1, obs-6
            BindingUnless not suitable, these codes SHALL be taken from DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason
            (extensible to http://hl7.org/fhir/ValueSet/data-absent-reason)

            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。


            Codes specifying why the result (Observation.value[x]) is missing.

            TypeCodeableConcept(TW CodeableConcept)
            Is Modifierfalse
            Requirements

            對於許多結果,必須處理測量中的異常值。


            For many results it is necessary to handle exceptional values in measurements.

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

            對一項檢驗檢查值的分類評估,例如:高、低、正常。


            A categorical assessment of an observation value. For example, high, low, normal.

            Short高、低、正常等。High, low, normal, etc.
            Comments

            歷史上用於實驗室結果【被稱為 「異常標記(abnormal flag)」】,它的使用延伸到其他與編碼解釋有關的使用情況中。通常報告為一個或多個簡單的緊密碼(compact code,一種可以解譯且具有最小平均字長的唯一資料代碼),這個資料項目經常被放置在報告和流程表的結果值的旁邊,以表示結果的意義或正常狀態。


            Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result.

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

            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。


            Codes identifying interpretations of observations.

            TypeCodeableConcept(TW CodeableConcept)
            Is Modifierfalse
            Requirements

            對於某些結果,特別是數值結果,需有一個解釋以便完全理解結果之意義。


            For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result.

            Alternate NamesAbnormal Flag
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            128. Observation.component.referenceRange
            Definition

            關於如何透過與正常值或建議範圍值的比較來解釋此值


            Guidance on how to interpret the value by comparison to a normal or recommended range.

            Short解釋此組成之檢驗驗查的結果值之指引Provides guide for interpretation of component result
            Comments

            大多數檢驗檢查只有一個通用的參考範圍值。系統 可能可以(MAY) 選擇限制只提供病人的相關參考範圍值(例如:具體的病人年齡、性別、體重和其他因素),但這可能是不可能的或也不合適。只要提供了一個以上的參考範圍值,就 建議應該(SHOULD) 提供不同年齡的參考範圍值差異。


            Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this might not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties.

            Control0..*
            TypeSeettp://hl7.org/fhir/StructureDefinition/Observation#Observation.referenceRange
            Is Modifierfalse
            Summaryfalse
            Requirements

            知道什麼值被認為是「正常的」,可以幫助評估某一特定結果的意義。需要能夠為不同的情境提供多個參考範圍值。


            Knowing what values are considered "normal" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts.

            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. Observation
            Definition

            對病人、設備或其他對象進行的測量和簡單判定。

            Short檢驗檢查,測量及簡單的判定。
            Comments

            Used for simple observations such as device measurements, laboratory atomic results, vital signs, height, weight, smoking status, comments, etc. Other resources are used to provide context for observations such as laboratory reports, etc.

            Control0..*
            Is Modifierfalse
            Summaryfalse
            Alternate NamesVital Signs, Measurement, Results, Tests
            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())
            obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present (dataAbsentReason.empty() or value.empty())
            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 (value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty())
            tw-core-4: 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()))
            2. Observation.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Observation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. Observation.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Observation 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. Observation.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. Observation.language
            Definition

            編寫此resource的語言

            Short用以表述Observation 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. Observation.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。

            ShortObservation 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. Observation.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. Observation.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. Observation.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. Observation.identifier
            Definition

            此檢驗檢查的唯一識別碼

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

            允許對檢驗檢查結果進行區分和參照

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

            依據的計劃、提議或醫令或其部分要求進行檢驗檢查。例如:一個MedicationRequest可能要求給病人藥之前要先進行實驗室檢查。

            Short依據的照護計畫/提議/醫令
            Control0..*
            TypeReference(TW Core CarePlan, DeviceRequest, ImmunizationRecommendation, TW Core MedicationRequest, NutritionOrder, TW Core ServiceRequest)
            Is Modifierfalse
            Summarytrue
            Requirements

            允許授權追踪檢驗檢查事件並追踪提議/建議是否有落實

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

            此特定的檢驗檢查(Observation)是一個更大事件中的一個組成或步驟。例如:一項處置裡的一項檢驗檢查。

            Short此檢驗檢查是哪個參照事件的一部分
            Comments

            使用encounter將一個檢驗檢查(Observation)與一個就醫(Encounter)連結起來。關於參照另一個Observation的作法,請參閱下面的Notes小節。

            Control0..*
            TypeReference(MedicationAdministration, TW Core MedicationDispense, TW Core MedicationStatement, TW Core Procedure, TW Core Immunization, TW Core ImagingStudy)
            Is Modifierfalse
            Summarytrue
            Alternate NamesContainer
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            24. Observation.status
            Definition

            結果值的狀態

            Shortregistered | preliminary | final | amended +
            Comments

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

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

            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。

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

            需要追踪單個結果狀態,有些結果在整個報告確定之前就已經確定了。

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

            可以正式參照一個專門術語或本體論來定義一個概念,或者也可以文字表述此概念。

            Short概念(concept)-參照一個專門術語或只是純文字。
            Comments

            並非所有的專門術語使用都符合這個一般模式。在某些情況下,資料模型不應該使用CodeableConcept而應直接使用Coding,並提供他們自己的結構來管理text、codings、translation、資料項目之間的關係、以及先組合配對/前組合式(pre-coordination)和後組合配對/後組合式(post-coordination)。

            Control1..*
            BindingThe codes SHOULD be taken from ObservationCategoryCodes
            (preferred to http://hl7.org/fhir/ValueSet/observation-category)

            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。

            TypeCodeableConcept(TW CodeableConcept)
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Requirements

            用於篩選取得及顯示之檢驗檢查

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

              A code that classifies the general type of observation being made.

              ShortClassification of type of observation
              Comments

              In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set.

              Control1..1
              BindingThe codes SHALL be taken from 臺灣衛福部資訊處Observation Clinical Result類型值集
              (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/observation-clinical-result-category)

              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。

              TypeCodeableConcept
              Is Modifierfalse
              Must Supporttrue
              Summaryfalse
              Requirements

              Used for filtering what observations are retrieved and displayed.

              Pattern Value{
                "coding" : [{
                  "system" : "http://terminology.hl7.org/CodeSystem/observation-category",
                  "code" : "laboratory"
                }]
              }
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              30. Observation.code
              Definition

              可以透過正式參照一個專門術語或本體論來定義一個概念,或者也可以文字表述此概念。

              Short概念(concept)-參照一個專門術語或只是純文字。
              Comments

              並非所有的專門術語使用都符合這個一般模式。在某些情況下,資料模型不應該使用CodeableConcept而應直接使用Coding,並提供他們自己的結構來管理text、codings、translation、資料項目之間的關係、以及先組合配對/前組合式(pre-coordination)和後組合配對/後組合式(post-coordination)。

              Control1..1
              This element is affected by the following invariants: ele-1
              BindingUnless not suitable, these codes SHALL be taken from LOINCCodes
              (extensible to http://hl7.org/fhir/ValueSet/observation-codes)

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

              TypeCodeableConcept(TW CodeableConcept)
              Is Modifierfalse
              Must Supporttrue
              Requirements

              知道正在進行的是哪種檢驗檢查是理解檢驗檢查的關鍵

              Alternate NamesName
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              32. Observation.code.id
              Definition

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

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

              擴充的資料項目

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

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

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

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

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

                允許使用者在不知道識別碼系統的情況下利用識別碼

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

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

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

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

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

                  應填入所綁定值集中的其中一個代碼。

                  TypeCoding(TW Coding)
                  Is Modifierfalse
                  Must Supporttrue
                  Requirements

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

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

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

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

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

                  Short擴充的資料項目
                  Comments

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

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

                    定義代碼中符號意義的代碼系統識別。

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

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

                    Control1..1
                    Typeuri
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Must Supporttrue
                    Summarytrue
                    Requirements

                    需要明確說明符號定義的來源

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

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

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

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

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

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

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

                    需要參照系統中的一個特定代碼

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

                    遵循系統的規則以呈現代碼含義的表示法

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

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

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

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

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

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

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

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

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

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

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

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

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

                    應填入所綁定值集中的其中一個代碼。

                    TypeCoding(TW Coding)
                    Is Modifierfalse
                    Must Supporttrue
                    Requirements

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

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

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

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

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

                    Short擴充的資料項目
                    Comments

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

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

                      定義代碼中符號意義的代碼系統識別。

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

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

                      Control1..1
                      Typeuri
                      Is Modifierfalse
                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                      Must Supporttrue
                      Summarytrue
                      Requirements

                      需要明確說明符號定義的來源

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

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

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

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

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

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

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

                      需要參照系統中的一個特定代碼

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

                      遵循系統的規則以呈現代碼含義的表示法

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

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

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

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

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

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

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

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

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

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

                      Short概念的文字表示法
                      Comments

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

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

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

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

                      此檢驗檢查是關於一位病人、一群病人、地點、或設備。如果檢驗檢查的實際焦點與對象(或其樣本、其部分或其區域)不同,則焦點資料項目或代碼本身會具體說明檢驗檢查的實際焦點。

                      Short檢驗檢查有關的對象及(或)事物
                      Comments

                      人們期望這個資料項目的cardinality為1...1。唯一可能缺少對象的情況是當檢驗檢查是由一個不認識病人的設備進行的。在這種情況下,應透過一些情境/通道對應(context/channel matching)技術將檢驗檢查與病人對應,此時,應更新檢驗檢查資訊。

                      Control1..1
                      TypeReference(TW Core Patient)
                      Is Modifierfalse
                      Must Supporttrue
                      Summarytrue
                      Requirements

                      如果你不知道他們是誰或關於什麼,檢驗檢查不會有值。

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

                      檢驗檢查的實際焦點,當它不是記錄病人時,代表是與病人有關的事物或人,如配偶、父母、胎兒或捐贈者。例如:母親的記錄中有關胎兒檢驗檢查。檢驗檢查的焦點也可以是現有的狀況、疾病或問題(condition)、介入(intervention)、此對象的飲食、對此對象的另一項檢驗檢查,或身體結構像是腫瘤或植入裝置。有一個案例是使用Observation Resource來取得母親是否已接受更換她的小孩的氣管插管訓練之資訊,在這個例子中,孩子是此記錄的病人,而母親是focus。

                      Short當檢驗檢查並非有關於與病人本身,檢驗檢查是關於什麼。
                      Comments

                      通常檢驗檢查的對象是一位病人或一群病人、地點或設備,檢驗檢查對象與直接測量內容之間的區別在observation.code已具體說明(例如: 「血糖」),不需要使用這個資料項目(focus)單獨表示。如果需要參照檢體,則使用specimen,如果需要一個代碼而不是一個resource,則使用bodysite來表示bodysites或標準擴充focusCode。

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

                      執行檢驗檢查的健康照護事件(例如:病人及健康照護提供人員的互動)

                      Short檢驗檢查是哪一次就醫時執行的
                      Comments

                      這通常指檢驗檢查發生於哪次就醫,但有些檢驗檢查可能是在就醫前或就醫後發生,但仍與就醫的情境有關(如入院前的實驗室檢驗檢查)。

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

                      對於某些檢驗檢查來說,知道某個檢驗檢查和某個特定的就醫事件之間的連結可能很重要。

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

                      宣告檢驗檢查值的產出時間或時間區段是真的。對於生物學研究對象—例如病人—這通常被稱為「生理相關時間」。這通常是處置的時間或採樣的時間,但很多時候不知道日期或時間的來源,只知道日期或時間本身。

                      Short檢驗檢查執行日期或時間區間
                      Comments

                      除非這是一份檢驗檢查的歷史報告,否則至少應該有一個日期。為了記錄不精確或「模煳」的時間(例如:測量「早餐後 」血糖),使用Timing datatype以允許測量能與常規生活事件連結。

                      Control1..1
                      TypeChoice of: dateTime, Period, Timing, instant
                      [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                      Is Modifierfalse
                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                      Must Supporttrue
                      Must Support TypesdateTime
                      Summarytrue
                      Requirements

                      知道一項檢驗檢查何時被認為是真的,對其相關性和確定趨勢都很重要。

                      Alternate NamesOccurrence
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      tw-core-3: Datetime must be at least to day. ($this is dateTime implies $this.toString().length() >= 10)
                      80. Observation.issued
                      Definition

                      此版本的檢驗檢查資訊可供健康照護提供人員取得的日期和時間,通常是在結果被審查與核實之後。

                      Short此版本檢驗檢查完成的日期或時間
                      Comments

                      對於不需要審查和核實的檢驗檢查值,發佈日期時間可能與resource本身的最後更新日期時間相同。對於需要對某些更新進行審查和核實的檢驗檢查,若為非臨床上的重要更新則不需要對新版本進行再次審查和驗證,所以發佈日期時間可能與resource本身的最後更新日期時間不一樣。

                      Control0..1
                      Typeinstant
                      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()))
                      82. Observation.performer
                      Definition

                      誰負責宣告檢驗檢查結果值為「真的」

                      Short誰負責這項檢驗檢查
                      Control0..*
                      TypeReference(TW Core Practitioner, TW Core Organization, TW Core Patient, TW Core PractitionerRole, TW Core CareTeam)
                      Is Modifierfalse
                      Must Supporttrue
                      Must Support TypesNo must-support rules about the choice of types/profiles
                      Summarytrue
                      Requirements

                      可以對此檢驗檢查有一定程度的信任,並指出後續問題的方向。

                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      84. Observation.value[x]
                      Definition

                      如果此資訊有一個簡單的值,則將其作為此項檢驗檢查的結果。

                      Short檢驗檢查的實際結果
                      Comments

                      一項檢驗檢查可能有:(1)單一值、(2)一個值及一組相關或組成之檢驗檢查的多個值、或者(3)只有一組相關或組成之檢驗檢查的多個值。如果有一個值,這個資料項目的datatype應該由Observation.code決定。如果這個資料項目是編碼或者如果與Observation.code相關的type定義一個編碼值,那麼將使用只有文字表述的CodeableConcept來代替字串。若需要更多的說明,請參閱下面Notes小節。

                      Control0..1
                      This element is affected by the following invariants: obs-7
                      TypeChoice of: Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period
                      [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                      Is Modifierfalse
                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                      Must Supporttrue
                      Must Support TypesChoice of: Quantity, CodeableConcept, string
                      Summarytrue
                      Requirements

                      通常一項檢驗檢查就會有一個值,雖然若它有錯誤或者它代表一組檢驗檢查可能不會有值。

                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      tw-core-5: SHALL use UCUM for coded quantity units. (ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org')
                      86. Observation.dataAbsentReason
                      Definition

                      提供資料項目Observation.value[x]中的預期值缺少的原因

                      Short缺少檢驗檢查結果的原因
                      Comments

                      空值(Null)或例外值可以在FHIR Observations中以兩種方式表示,一種方法是簡單地將它們含括在值集中,並在值中表示例外。例如:血清檢測的測量值可以是「檢測到」、「未檢測到」、「不確定」或「檢測未完成」。

                      另一種方法是使用資料項目value呈現實際檢驗檢查值,並使用資料項目dataAbsentReason來明確記錄例外值。例如:當測量沒有完成,可使用dataAbsentReason代碼「error」。請注意,只有在有值的情況下,才可以報告檢驗檢查。例如:只有在>0的情況下才可能報告細胞計數的差值。由於有這些選項,所以需要有使用案例協議(use-case agreements)來解釋一般檢驗檢查的例外值。

                      Control0..1
                      This element is affected by the following invariants: ele-1
                      BindingUnless not suitable, these codes SHALL be taken from DataAbsentReason
                      (extensible to http://hl7.org/fhir/ValueSet/data-absent-reason)

                      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。

                      TypeCodeableConcept(TW CodeableConcept)
                      Is Modifierfalse
                      Must Supporttrue
                      Requirements

                      對於許多結果,必須處理測量中的異常值。

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

                      對一項檢驗檢查值的分類評估,例如:高、低、正常。

                      Short高、低、正常等
                      Comments

                      歷史上用於實驗室結果【被稱為 「異常標記(abnormal flag)」】,它的使用延伸到其他與編碼解釋有關的使用情況中。通常報告為一個或多個簡單的緊密碼(compact code,一種可以解譯且具有最小平均字長的唯一資料代碼),這個資料項目經常被放置在報告和流程表的結果值的旁邊,以表示結果的意義或正常狀態。

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

                      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。

                      TypeCodeableConcept(TW CodeableConcept)
                      Is Modifierfalse
                      Requirements

                      對於某些結果,特別是數值結果,需有一個解釋以便完全理解結果之意義。

                      Alternate NamesAbnormal Flag
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      90. Observation.note
                      Definition

                      關於檢驗檢查或結果的解說

                      Short關於此檢驗檢查之解說
                      Comments

                      可包括關於檢驗檢查的一般陳述,或關於重要的、非預期的或不可靠的結果值的陳述,或與資料項目interpretation有關的來源資訊。

                      Control0..*
                      TypeAnnotation
                      Is Modifierfalse
                      Summaryfalse
                      Requirements

                      需能提供純文字表述的附加資訊

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

                      表示在檢驗檢查對象身上進行檢驗檢查的部位(即目標部位)

                      Short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。
                      Comments

                      只有在Observation.code中的代碼未隱含時才會使用。在許多系統中,這可能被表示為一個相關的檢驗檢查,而不是一個行內的組成之檢驗檢查(inline component)。

                      如果使用案例(use-case)要求將BodySite作為一個單獨的resource來處理(例如:單獨指明和追踪),那麼就使用標準的資料項目擴充方式來擴充bodySite。

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

                      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。

                      TypeCodeableConcept(TW CodeableConcept)
                      Is Modifierfalse
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      94. Observation.method
                      Definition

                      指明用於執行檢驗檢查的機制

                      Short此檢驗檢查使用何種方法完成
                      Comments

                      只有在Observation.code中的代碼未隱含此資料項目概念時才會使用。

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

                      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。

                      TypeCodeableConcept(TW CodeableConcept)
                      Is Modifierfalse
                      Requirements

                      在某些情況下,方法會影響結果,因此用於確認結果是否可以比較或確認結果的顯著性(significance)。

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

                      進行這項檢驗檢查時使用的檢體

                      Short此檢驗檢查的檢體
                      Comments

                      只有在Observation.code中的代碼未隱含此資料項目概念時才會使用。 檢驗檢查不是針對檢體本身進行,而是針對對象,但在很多情況下是透過檢體的方式進行檢驗檢查。請注意,雖然經常涉及到檢體,但並不總是明確地對其進行追踪和報告。還要注意的是Observation resources可在明確追踪檢體的情境下使用(例如:Diagnostic Report)。

                      Control0..1
                      TypeReference(TW Core Specimen)
                      Is Modifierfalse
                      Summaryfalse
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      98. Observation.device
                      Definition

                      用於產生檢驗檢查資料的設備

                      Short(測量)設備
                      Comments

                      請注意,這不是用來表示結果傳輸的設備,例如:閘道器(gateway)等可在相關情況下使用 Provenance resource進行記錄。

                      Control0..1
                      TypeReference(Device, DeviceMetric)
                      Is Modifierfalse
                      Summaryfalse
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      100. Observation.referenceRange
                      Definition

                      指導如何透過與正常或建議範圍值的比較來解釋此值。多個參考範圍值以「OR」解釋。換句話說,為了代表兩個不同的目標人群,將使用兩個referenceRange資料項目。

                      Short解釋結果值的指引。 obs-3:必須至少有低、高或文字表述。
                      Comments

                      大多數檢驗檢查只有一個通用的參考範圍值。系統 可能可以(MAY) 選擇限制只提供病人的相關參考範圍值(例如:具體的病人年齡、性別、體重和其他因素),但這可能是不可能的或也不合適。只要提供了一個以上的參考範圍值,就 建議應該(SHOULD) 提供不同年齡的參考範圍值差異。

                      Control0..*
                      TypeBackboneElement
                      Is Modifierfalse
                      Summaryfalse
                      Requirements

                      知道什麼值被認為是「正常的」,可以幫助評估某一特定結果的意義。需要能夠為不同的情境提供多個參考範圍值。

                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      obs-3: Must have at least a low or a high or text (low.exists() or high.exists() or text.exists())
                      102. Observation.referenceRange.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
                      104. Observation.referenceRange.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())
                      106. Observation.referenceRange.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())
                      108. Observation.referenceRange.low
                      Definition

                      參考範圍值的下限值。參考範圍值endpoint的下限值包含在此值中(例如:參考範圍值是>=5 - <=9)。如果省略下限值,則被認為是沒有意義的(例如:參考範圍值是<=2.3)。

                      Short參考範圍值的下限值,如果相關。
                      Control0..1
                      This element is affected by the following invariants: obs-3
                      TypeQuantity(SimpleQuantity)
                      Is Modifierfalse
                      Summaryfalse
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      110. Observation.referenceRange.high
                      Definition

                      參考範圍值的下限值。參考範圍值endpoint的下限值包含在此值中(例如:參考範圍值是>=5 - <=9)。如果省略下限值,則被認為是沒有意義的(例如:參考範圍值是<=2.3)。

                      Short參考範圍值的上限值,如果相關。
                      Control0..1
                      This element is affected by the following invariants: obs-3
                      TypeQuantity(SimpleQuantity)
                      Is Modifierfalse
                      Summaryfalse
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      112. Observation.referenceRange.type
                      Definition

                      代碼表明適用的目標人群,例如:正常值或治療範圍值。

                      Short參考範圍值的限定詞
                      Comments

                      如果有一個以上的範圍值,此資料項目 建議應該(SHOULD) 填寫。如果這個資料項目不存在,則假定是正常範圍值。

                      Control0..1
                      This element is affected by the following invariants: ele-1
                      BindingThe codes SHOULD be taken from ObservationReferenceRangeMeaningCodes
                      (preferred to http://hl7.org/fhir/ValueSet/referencerange-meaning)

                      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。

                      TypeCodeableConcept(TW CodeableConcept)
                      Is Modifierfalse
                      Requirements

                      需要能夠說出這是什麼樣的參考範圍值:正常的、建議的、治療的等,以便正確解釋。

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

                      代碼表明此參考範圍值所適用的目標人群,例如:一個參考範圍值可能是一般人群或特定的性別或種族。多個適用對象需以「AND」解釋目標人群。例如:為了表示一個非裔美國人女性的目標人群,將同時使用女性的代碼和非裔美國人的代碼。

                      Short參考範圍值是用適用的對象或人口群
                      Comments

                      如果有一個以上的範圍值,此資料項目 建議應該(SHOULD) 填寫。如果這個資料項目不存在,則假定是正常範圍值。

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

                      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。

                      TypeCodeableConcept(TW CodeableConcept)
                      Is Modifierfalse
                      Requirements

                      需要能夠指明目標人群以進行適當的解釋。

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

                      此參考範圍值適用的年齡,如果意思是說足月時的週數,這就是指新生兒年齡。

                      Short適用的年齡範圍值,如果相關。
                      Control0..1
                      TypeRange
                      Is Modifierfalse
                      Summaryfalse
                      Requirements

                      有些分析隨著年齡的增長變化很大

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

                      檢驗檢查中以文字表述的參考範圍值,可在不適合以定量範圍值呈現某項檢驗檢查時使用。例如:「陰性」的參照值或 「正常」的清單/列表。

                      Short檢驗檢查中以文字表述的參考範圍值
                      Control0..1
                      Typestring
                      Is Modifierfalse
                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                      Summaryfalse
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      120. Observation.hasMember
                      Definition

                      這項檢驗檢查是一組檢驗檢查,例如:一個套組(battery)、一個檢驗套組(panel)或一組生命徵象測量,其組成的檢驗檢查為此資料項目的目標resource。

                      Short屬於此組檢驗檢查的相關Resource
                      Comments

                      使用這個資料項目時,一項檢驗檢查通常會有一個值或者一組相關的resources,儘管在某些情況下兩者都可能存在。有關討論如何將Observations組合在一起的方法,請參閱下面的Notes小節。請注意,系統可能針對問卷調查的結果( QuestionnaireResponse)計算成一個最終的分數,並將這個分數表示為一個Observation。

                      Control0..*
                      TypeReference(TW Core Observation Laboratory Result, TW Core QuestionnaireResponse, MolecularSequence)
                      Is Modifierfalse
                      Summarytrue
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      122. Observation.derivedFrom
                      Definition

                      目標resource為一種測量,此檢驗檢查就是從那個測量中得出。例如:陰離子間隙(an anion gap)或胎兒的測量值是從超音波影像計算而得。

                      Short檢驗檢查源自哪些相關測量
                      Comments

                      在這個資料項目中列出可以代表臨床檢檢查和其他測量的所有參照選項,可能是衍生值的來源。最常見參照另一個Observation,關於Observations如何組合在一起的討論,請參閱下面的Notes小節。

                      Control0..*
                      TypeReference(TW Core DocumentReference, TW Core ImagingStudy, TW Core Media, TW Core QuestionnaireResponse, TW Core Observation Laboratory Result, MolecularSequence)
                      Is Modifierfalse
                      Summarytrue
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      124. Observation.component
                      Definition

                      有有些檢驗檢查有多個組成之檢驗檢查,這些組成之檢驗檢查被表達為具有相同屬性的獨立的代碼值對(code value pair)。例子包括血壓測量的收縮壓和舒張壓即為組成之檢驗檢查(component observations),以及遺傳學檢驗檢查的多個組成之檢驗檢查。

                      Short組成之(部分)檢驗檢查的檢驗結果
                      Comments

                      有關如何組合Observations的方法討論,請參閱下面的Notes小節。

                      Control0..*
                      TypeBackboneElement
                      Is Modifierfalse
                      Must Supporttrue
                      Summarytrue
                      Requirements

                      組成之檢驗檢查在Obsrvation resource中與主要檢驗檢查共享相同的屬性,並且總是被視為單個檢驗檢查的一部分(它們是不可分離的)。然而,主要檢驗檢查的參考範圍值並不被組成之檢驗檢查所繼承,在適當的時候需給予每項組成之檢驗檢查參考範圍值。

                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      126. Observation.component.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
                      128. Observation.component.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())
                      130. Observation.component.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())
                      132. Observation.component.code
                      Definition

                      描述所觀察到的情況,有時這被稱為檢驗檢查「代碼」。

                      Short組成之檢驗檢查的型別(代碼/型別)
                      Comments

                      所有的code-value和component.code-component.value都需要考慮到,以正確理解檢驗檢查的意義。

                      Control1..1
                      This element is affected by the following invariants: ele-1
                      BindingFor example codes, see LOINC實驗室檢驗檢查值集
                      (example to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-observation-code)

                      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。

                      TypeCodeableConcept(TW CodeableConcept)
                      Is Modifierfalse
                      Must Supporttrue
                      Requirements

                      知道正在進行的是哪種檢驗檢查是理解檢驗檢查的關鍵

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

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

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

                      擴充的資料項目

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

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

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

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

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

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

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

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

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

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

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

                          應填入所綁定值集中的其中一個代碼。

                          TypeCoding(TW Coding)
                          Is Modifierfalse
                          Must Supporttrue
                          Requirements

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

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

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

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

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

                          Short擴充的資料項目
                          Comments

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

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

                            定義代碼中符號意義的代碼系統識別

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

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

                            Control1..1
                            Typeuri
                            Is Modifierfalse
                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                            Must Supporttrue
                            Summarytrue
                            Requirements

                            需要明確說明符號定義的來源

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

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

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

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

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

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

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

                            需要參照系統中的一個特定代碼

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

                            遵循系統的規則以呈現代碼含義的表示法

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

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

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

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

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

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

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

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

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

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

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

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

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

                            應填入所綁定值集中的其中一個代碼。

                            TypeCoding(TW Coding)
                            Is Modifierfalse
                            Must Supporttrue
                            Requirements

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

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

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

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

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

                            Short擴充的資料項目
                            Comments

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

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

                              定義代碼中符號意義的代碼系統識別

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

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

                              Control1..1
                              Typeuri
                              Is Modifierfalse
                              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                              Must Supporttrue
                              Summarytrue
                              Requirements

                              需要明確說明符號定義的來源

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

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

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

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

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

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

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

                              需要參照系統中的一個特定代碼

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

                              遵循系統的規則以呈現代碼含義的表示法

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

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

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

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

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

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

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

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

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

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

                              Short概念的文字表示法
                              Comments

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

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

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

                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                              174. Observation.component.value[x]
                              Definition

                              如果資訊中帶有一個值(simple value)則其可作為檢驗檢查的結果。

                              Short組成之檢驗檢查的實際結果
                              Comments

                              一項檢驗檢查可能有一個值(如Apgar評分)和組成之檢驗檢查值(Apgar評分所來自多項檢驗檢查)。如果有一個值,這個資料項目的datatype應該由Observation.code決定。如果這個資料項目是編碼或者如果與Observation.code相關的type定義一個編碼值,那麼將使用只有文字表述的CodeableConcept來代替字串。若需要更多的說明,請參閱下面Notes小節。

                              Control0..1
                              TypeChoice of: Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period
                              [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                              Is Modifierfalse
                              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                              Must Supporttrue
                              Must Support TypesNo must-support rules about the choice of types/profiles
                              Summarytrue
                              Requirements

                              通常一項檢驗檢查就會有一個值,雖然若它有錯誤或者它代表一組檢驗檢查可能不會有值。

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

                              提供資料項目Observation.component.value[x]中的預期值缺少的原因

                              Short為什麼缺少組成之檢驗檢查結果
                              Comments

                              空值(Null)或例外值可以在FHIR Observations中以兩種方式表示,一種方法是簡單地將它們含括在值集中,並在值中表示例外。例如:血清檢測的測量值可以是「檢測到」、「未檢測到」、「不確定」或「檢測未完成」。

                              另一種方法是使用資料項目value呈現實際檢驗檢查值,並使用資料項目dataAbsentReason來明確記錄例外值。例如:當測量沒有完成,可使用dataAbsentReason代碼「error」。請注意,只有在有值的情況下,才可以報告檢驗檢查。例如:只有在>0的情況下才可能報告細胞計數的差值。由於有這些選項,所以需要有使用案例協議(use-case agreements)來解釋一般檢驗檢查的例外值。

                              Control0..1
                              This element is affected by the following invariants: ele-1
                              BindingUnless not suitable, these codes SHALL be taken from DataAbsentReason
                              (extensible to http://hl7.org/fhir/ValueSet/data-absent-reason)

                              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。

                              TypeCodeableConcept(TW CodeableConcept)
                              Is Modifierfalse
                              Requirements

                              對於許多結果,必須處理測量中的異常值。

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

                              對一項檢驗檢查值的分類評估,例如:高、低、正常。

                              Short高、低、正常等。
                              Comments

                              歷史上用於實驗室結果【被稱為 「異常標記(abnormal flag)」】,它的使用延伸到其他與編碼解釋有關的使用情況中。通常報告為一個或多個簡單的緊密碼(compact code,一種可以解譯且具有最小平均字長的唯一資料代碼),這個資料項目經常被放置在報告和流程表的結果值的旁邊,以表示結果的意義或正常狀態。

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

                              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。

                              TypeCodeableConcept(TW CodeableConcept)
                              Is Modifierfalse
                              Requirements

                              對於某些結果,特別是數值結果,需有一個解釋以便完全理解結果之意義。

                              Alternate NamesAbnormal Flag
                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                              180. Observation.component.referenceRange
                              Definition

                              關於如何透過與正常值或建議範圍值的比較來解釋此值

                              Short解釋此組成之檢驗驗查的結果值之指引
                              Comments

                              大多數檢驗檢查只有一個通用的參考範圍值。系統 可能可以(MAY) 選擇限制只提供病人的相關參考範圍值(例如:具體的病人年齡、性別、體重和其他因素),但這可能是不可能的或也不合適。只要提供了一個以上的參考範圍值,就 建議應該(SHOULD) 提供不同年齡的參考範圍值差異。

                              Control0..*
                              TypeSeettp://hl7.org/fhir/StructureDefinition/Observation#Observation.referenceRange
                              Is Modifierfalse
                              Summaryfalse
                              Requirements

                              知道什麼值被認為是「正常的」,可以幫助評估某一特定結果的意義。需要能夠為不同的情境提供多個參考範圍值。

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