臺灣中醫實作指引
0.1.0 - ci-build
臺灣中醫實作指引
0.1.0 - ci-build
臺灣中醫實作指引, published by 衛生福利部國家中醫藥研究所. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/nricmig/Nricm_TWCMIG/ and changes regularly. See the Directory of published versions
| Official URL: https://hitstdio.ntunhs.edu.tw/twcm/StructureDefinition/clinicalimpression-twcm | Version: 0.1.0 | |||
| Draft as of 2026-10-28 | Computable Name: ClinicalImpressionTWCM | |||
此中醫辨證評估(ClinicalImpression TWCM)Profile說明本IG如何進一步定義FHIR的ClinicalImpression Resource以呈現中醫門診單之望聞問切客觀描述、四診紀錄參照，以及病因、病性、病位、病勢與證型等辨證結果。四診（望、聞、問、切）為證據，以Observation記錄並由investigation參照；辨證為推論，記錄於finding。
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:  |
|---|---|---|---|---|
  ClinicalImpression |
0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
  implicitRules |
0..1 | uri | A set of rules under which this content was created | |
 modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |
| status |
1..1 | code | in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. Required Pattern: completed (extensions allowed) | |
 subject |
1..1 | Reference(病人資料(Patient TWCM)) | Patient or group assessed | |
| encounter |
0..1 | Reference(就醫事件(Encounter TWCM)) | Encounter created as part of | |
  effective[x] |
0..1 | Time of assessment | ||
 effectiveDateTime |
dateTime | |||
  effectivePeriod |
Period | |||
| assessor |
0..1 | Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole) | The clinician performing the assessment | |
| problem |
0..* | Reference(病情、問題或診斷(ConditionDiagnosis TWCM) | 病人主訴(ConditionChiefComplaint TWCM) | 過敏或不耐症(AllergyIntolerance TWCM)) | Relevant impressions of patient state | |
 Slices for investigation |
0..* | BackboneElement | 四診紀錄。依望、聞、問、切分別參照對應的Observation Slice: Unordered, Open by pattern:code Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
  investigation:All Slices |
Content/Rules for all slices | |||
  modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
 code |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. | |
 investigation:inspection |
0..1 | BackboneElement | 望診 | |
 modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| code |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. Required Pattern: | |
 item |
1..1 | Reference(望診(ObservationInspection TWCM)) | Record of a specific investigation | |
| investigation:listeningSmelling |
0..1 | BackboneElement | 聞診 | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| code |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. Required Pattern: | |
| item |
1..1 | Reference(聞診(ObservationListeningSmelling TWCM)) | Record of a specific investigation | |
| investigation:inquiry |
0..1 | BackboneElement | 問診 | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| code |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. Required Pattern: | |
| item |
1..1 | Reference(問診(ObservationInquiry TWCM)) | Record of a specific investigation | |
 investigation:palpation |
0..1 | BackboneElement | 切診 | |
 modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| code |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. Required Pattern: | |
| item |
1..1 | Reference(切診(ObservationPalpation TWCM)) | Record of a specific investigation | |
| summary |
1..1 | string | [應填入中醫門診單之望聞問切客觀描述Description] | |
 Slices for finding |
0..* | BackboneElement | 辨證結果。病因、病性、病位、病勢以固定文字標示項目，內容填於basis；證型以itemReference參照ConditionSyndromeTypeTWCM Slice: Unordered, Open by value:itemCodeableConcept.text Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| finding:All Slices |
Content/Rules for all slices | |||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| finding:diseaseCause |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
 itemCodeableConcept |
1..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |
 text |
1..1 | string | Plain text representation of the concept Fixed Value: 病因 (no extensions allowed) | |
| basis |
1..1 | string | [應填入中醫門診單之病因Disease Cause] | |
| finding:diseaseNature |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| itemCodeableConcept |
1..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病性 (no extensions allowed) | |
| basis |
1..1 | string | [應填入中醫門診單之病性Disease Nature] | |
| finding:diseaseLocation |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| itemCodeableConcept |
1..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病位 (no extensions allowed) | |
| basis |
1..1 | string | [應填入中醫門診單之病位Disease Location] | |
| finding:diseaseTrend |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| itemCodeableConcept |
1..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病勢 (no extensions allowed) | |
| basis |
1..1 | string | [應填入中醫門診單之病勢Disease Trend] | |
| finding:syndromeType |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| itemCodeableConcept |
1..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 證型 (no extensions allowed) | |
| itemReference |
1..1 | Reference(病人證型(ConditionSyndromeType TWCM)) | 參照本次辨證所得之病人證型 | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| ClinicalImpression.status | Base | required | Clinical Impression Status | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.investigation.code | Base | example | Investigation Type | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.investigation:inspection.code | Base | example | Investigation Type | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.investigation:listeningSmelling.code | Base | example | Investigation Type | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.investigation:inquiry.code | Base | example | Investigation Type | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.investigation:palpation.code | Base | example | Investigation Type | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding:diseaseCause.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding:diseaseNature.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding:diseaseLocation.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding:diseaseTrend.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding:syndromeType.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
This structure is derived from ClinicalImpression
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| ClinicalImpression |
ClinicalImpression | |||
| status |
1..1 | code | in-progress | completed | entered-in-error Required Pattern: completed (extensions allowed) | |
| subject |
1..1 | Reference(病人資料(Patient TWCM)) | Patient or group assessed | |
| encounter |
0..1 | Reference(就醫事件(Encounter TWCM)) | Encounter created as part of | |
| effective[x] |
0..1 | dateTime, Period | Time of assessment | |
| assessor |
0..1 | Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole) | The clinician performing the assessment | |
| problem |
0..* | Reference(病情、問題或診斷(ConditionDiagnosis TWCM) | 病人主訴(ConditionChiefComplaint TWCM) | 過敏或不耐症(AllergyIntolerance TWCM)) | Relevant impressions of patient state | |
| Slices for investigation |
0..* | BackboneElement | 四診紀錄。依望、聞、問、切分別參照對應的Observation Slice: Unordered, Open by pattern:code Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| investigation:inspection |
0..1 | BackboneElement | 望診 | |
| code |
1..1 | CodeableConcept | A name/code for the set Required Pattern: | |
| item |
1..1 | Reference(望診(ObservationInspection TWCM)) | Record of a specific investigation | |
| investigation:listeningSmelling |
0..1 | BackboneElement | 聞診 | |
| code |
1..1 | CodeableConcept | A name/code for the set Required Pattern: | |
| item |
1..1 | Reference(聞診(ObservationListeningSmelling TWCM)) | Record of a specific investigation | |
| investigation:inquiry |
0..1 | BackboneElement | 問診 | |
| code |
1..1 | CodeableConcept | A name/code for the set Required Pattern: | |
| item |
1..1 | Reference(問診(ObservationInquiry TWCM)) | Record of a specific investigation | |
| investigation:palpation |
0..1 | BackboneElement | 切診 | |
| code |
1..1 | CodeableConcept | A name/code for the set Required Pattern: | |
| item |
1..1 | Reference(切診(ObservationPalpation TWCM)) | Record of a specific investigation | |
| summary |
1..1 | string | [應填入中醫門診單之望聞問切客觀描述Description] | |
| Slices for finding |
0..* | BackboneElement | 辨證結果。病因、病性、病位、病勢以固定文字標示項目，內容填於basis；證型以itemReference參照ConditionSyndromeTypeTWCM Slice: Unordered, Open by value:itemCodeableConcept.text Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| finding:diseaseCause |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |
| itemCodeableConcept |
1..1 | CodeableConcept | What was found | |
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病因 (no extensions allowed) | |
| basis |
1..1 | string | [應填入中醫門診單之病因Disease Cause] | |
| finding:diseaseNature |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |
| itemCodeableConcept |
1..1 | CodeableConcept | What was found | |
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病性 (no extensions allowed) | |
| basis |
1..1 | string | [應填入中醫門診單之病性Disease Nature] | |
| finding:diseaseLocation |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |
| itemCodeableConcept |
1..1 | CodeableConcept | What was found | |
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病位 (no extensions allowed) | |
| basis |
1..1 | string | [應填入中醫門診單之病位Disease Location] | |
| finding:diseaseTrend |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |
| itemCodeableConcept |
1..1 | CodeableConcept | What was found | |
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病勢 (no extensions allowed) | |
| basis |
1..1 | string | [應填入中醫門診單之病勢Disease Trend] | |
| finding:syndromeType |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |
| itemCodeableConcept |
1..1 | CodeableConcept | What was found | |
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 證型 (no extensions allowed) | |
| itemReference |
1..1 | Reference(病人證型(ConditionSyndromeType TWCM)) | 參照本次辨證所得之病人證型 | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| ClinicalImpression |
0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
0..1 | Meta | Metadata about the resource | |||||
| implicitRules |
0..1 | uri | A set of rules under which this content was created | |||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
 extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
| identifier |
0..* | Identifier | Business identifier | |||||
| status |
1..1 | code | in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. Required Pattern: completed (extensions allowed) | |||||
| statusReason |
0..1 | CodeableConcept | Reason for current status Binding Description: (example): Codes identifying the reason for the current state of a clinical impression. | |||||
| code |
0..1 | CodeableConcept | Kind of assessment performed Binding Description: (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed. | |||||
| description |
0..1 | string | Why/how the assessment was performed | |||||
| subject |
1..1 | Reference(病人資料(Patient TWCM)) | Patient or group assessed | |||||
| encounter |
0..1 | Reference(就醫事件(Encounter TWCM)) | Encounter created as part of | |||||
| effective[x] |
0..1 | Time of assessment | ||||||
| effectiveDateTime |
dateTime | |||||||
| effectivePeriod |
Period | |||||||
| date |
0..1 | dateTime | When the assessment was documented | |||||
| assessor |
0..1 | Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole) | The clinician performing the assessment | |||||
| previous |
0..1 | Reference(ClinicalImpression) | Reference to last assessment | |||||
| problem |
0..* | Reference(病情、問題或診斷(ConditionDiagnosis TWCM) | 病人主訴(ConditionChiefComplaint TWCM) | 過敏或不耐症(AllergyIntolerance TWCM)) | Relevant impressions of patient state | |||||
| Slices for investigation |
0..* | BackboneElement | 四診紀錄。依望、聞、問、切分別參照對應的Observation Slice: Unordered, Open by pattern:code Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| investigation:All Slices |
Content/Rules for all slices | |||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| code |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. | |||||
| item |
0..* | Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media) | Record of a specific investigation | |||||
| investigation:inspection |
0..1 | BackboneElement | 望診 | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| code |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. Required Pattern: | |||||
| item |
1..1 | Reference(望診(ObservationInspection TWCM)) | Record of a specific investigation | |||||
| investigation:listeningSmelling |
0..1 | BackboneElement | 聞診 | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| code |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. Required Pattern: | |||||
| item |
1..1 | Reference(聞診(ObservationListeningSmelling TWCM)) | Record of a specific investigation | |||||
| investigation:inquiry |
0..1 | BackboneElement | 問診 | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| code |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. Required Pattern: | |||||
| item |
1..1 | Reference(問診(ObservationInquiry TWCM)) | Record of a specific investigation | |||||
| investigation:palpation |
0..1 | BackboneElement | 切診 | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| code |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. Required Pattern: | |||||
| item |
1..1 | Reference(切診(ObservationPalpation TWCM)) | Record of a specific investigation | |||||
| protocol |
0..* | uri | Clinical Protocol followed | |||||
| summary |
1..1 | string | [應填入中醫門診單之望聞問切客觀描述Description] | |||||
| Slices for finding |
0..* | BackboneElement | 辨證結果。病因、病性、病位、病勢以固定文字標示項目，內容填於basis；證型以itemReference參照ConditionSyndromeTypeTWCM Slice: Unordered, Open by value:itemCodeableConcept.text Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| finding:All Slices |
Content/Rules for all slices | |||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| itemCodeableConcept |
0..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |||||
| itemReference |
0..1 | Reference(Condition | Observation | Media) | What was found | |||||
| basis |
0..1 | string | Which investigations support finding | |||||
| finding:diseaseCause |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| itemCodeableConcept |
1..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
0..* | Coding | Code defined by a terminology system | |||||
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病因 (no extensions allowed) | |||||
| itemReference |
0..1 | Reference(Condition | Observation | Media) | What was found | |||||
| basis |
1..1 | string | [應填入中醫門診單之病因Disease Cause] | |||||
| finding:diseaseNature |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| itemCodeableConcept |
1..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
0..* | Coding | Code defined by a terminology system | |||||
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病性 (no extensions allowed) | |||||
| itemReference |
0..1 | Reference(Condition | Observation | Media) | What was found | |||||
| basis |
1..1 | string | [應填入中醫門診單之病性Disease Nature] | |||||
| finding:diseaseLocation |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| itemCodeableConcept |
1..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
0..* | Coding | Code defined by a terminology system | |||||
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病位 (no extensions allowed) | |||||
| itemReference |
0..1 | Reference(Condition | Observation | Media) | What was found | |||||
| basis |
1..1 | string | [應填入中醫門診單之病位Disease Location] | |||||
| finding:diseaseTrend |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| itemCodeableConcept |
1..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
0..* | Coding | Code defined by a terminology system | |||||
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病勢 (no extensions allowed) | |||||
| itemReference |
0..1 | Reference(Condition | Observation | Media) | What was found | |||||
| basis |
1..1 | string | [應填入中醫門診單之病勢Disease Trend] | |||||
| finding:syndromeType |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| itemCodeableConcept |
1..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
0..* | Coding | Code defined by a terminology system | |||||
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 證型 (no extensions allowed) | |||||
| itemReference |
1..1 | Reference(病人證型(ConditionSyndromeType TWCM)) | 參照本次辨證所得之病人證型 | |||||
| basis |
0..1 | string | Which investigations support finding | |||||
| prognosisCodeableConcept |
0..* | CodeableConcept | Estimate of likely outcome Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings. | |||||
| prognosisReference |
0..* | Reference(RiskAssessment) | RiskAssessment expressing likely outcome | |||||
| supportingInfo |
0..* | Reference(Resource) | Information supporting the clinical impression | |||||
| note |
0..* | Annotation | Comments made about the ClinicalImpression | |||||
| Documentation for this format | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| ClinicalImpression.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.status | Base | required | Clinical Impression Status | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.statusReason | Base | example | Not State | Unknown | |
| ClinicalImpression.code | Base | example | Not State | Unknown | |
| ClinicalImpression.investigation.code | Base | example | Investigation Type | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.investigation:inspection.code | Base | example | Investigation Type | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.investigation:listeningSmelling.code | Base | example | Investigation Type | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.investigation:inquiry.code | Base | example | Investigation Type | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.investigation:palpation.code | Base | example | Investigation Type | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding:diseaseCause.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding:diseaseNature.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding:diseaseLocation.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding:diseaseTrend.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding:syndromeType.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.prognosisCodeableConcept | Base | example | Clinical Impression Prognosis | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
This structure is derived from ClinicalImpression
Summary
Mandatory: 1 element(19 nested mandatory elements)
Must-Support: 29 elements
Fixed: 5 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| ClinicalImpression |
0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
| implicitRules |
0..1 | uri | A set of rules under which this content was created | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |
| status |
1..1 | code | in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. Required Pattern: completed (extensions allowed) | |
| subject |
1..1 | Reference(病人資料(Patient TWCM)) | Patient or group assessed | |
| encounter |
0..1 | Reference(就醫事件(Encounter TWCM)) | Encounter created as part of | |
| effective[x] |
0..1 | Time of assessment | ||
| effectiveDateTime |
dateTime | |||
| effectivePeriod |
Period | |||
| assessor |
0..1 | Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole) | The clinician performing the assessment | |
| problem |
0..* | Reference(病情、問題或診斷(ConditionDiagnosis TWCM) | 病人主訴(ConditionChiefComplaint TWCM) | 過敏或不耐症(AllergyIntolerance TWCM)) | Relevant impressions of patient state | |
| Slices for investigation |
0..* | BackboneElement | 四診紀錄。依望、聞、問、切分別參照對應的Observation Slice: Unordered, Open by pattern:code Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| investigation:All Slices |
Content/Rules for all slices | |||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| code |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. | |
| investigation:inspection |
0..1 | BackboneElement | 望診 | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| code |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. Required Pattern: | |
| item |
1..1 | Reference(望診(ObservationInspection TWCM)) | Record of a specific investigation | |
| investigation:listeningSmelling |
0..1 | BackboneElement | 聞診 | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| code |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. Required Pattern: | |
| item |
1..1 | Reference(聞診(ObservationListeningSmelling TWCM)) | Record of a specific investigation | |
| investigation:inquiry |
0..1 | BackboneElement | 問診 | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| code |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. Required Pattern: | |
| item |
1..1 | Reference(問診(ObservationInquiry TWCM)) | Record of a specific investigation | |
| investigation:palpation |
0..1 | BackboneElement | 切診 | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| code |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. Required Pattern: | |
| item |
1..1 | Reference(切診(ObservationPalpation TWCM)) | Record of a specific investigation | |
| summary |
1..1 | string | [應填入中醫門診單之望聞問切客觀描述Description] | |
| Slices for finding |
0..* | BackboneElement | 辨證結果。病因、病性、病位、病勢以固定文字標示項目，內容填於basis；證型以itemReference參照ConditionSyndromeTypeTWCM Slice: Unordered, Open by value:itemCodeableConcept.text Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| finding:All Slices |
Content/Rules for all slices | |||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| finding:diseaseCause |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| itemCodeableConcept |
1..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病因 (no extensions allowed) | |
| basis |
1..1 | string | [應填入中醫門診單之病因Disease Cause] | |
| finding:diseaseNature |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| itemCodeableConcept |
1..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病性 (no extensions allowed) | |
| basis |
1..1 | string | [應填入中醫門診單之病性Disease Nature] | |
| finding:diseaseLocation |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| itemCodeableConcept |
1..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病位 (no extensions allowed) | |
| basis |
1..1 | string | [應填入中醫門診單之病位Disease Location] | |
| finding:diseaseTrend |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| itemCodeableConcept |
1..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病勢 (no extensions allowed) | |
| basis |
1..1 | string | [應填入中醫門診單之病勢Disease Trend] | |
| finding:syndromeType |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| itemCodeableConcept |
1..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 證型 (no extensions allowed) | |
| itemReference |
1..1 | Reference(病人證型(ConditionSyndromeType TWCM)) | 參照本次辨證所得之病人證型 | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| ClinicalImpression.status | Base | required | Clinical Impression Status | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.investigation.code | Base | example | Investigation Type | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.investigation:inspection.code | Base | example | Investigation Type | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.investigation:listeningSmelling.code | Base | example | Investigation Type | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.investigation:inquiry.code | Base | example | Investigation Type | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.investigation:palpation.code | Base | example | Investigation Type | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding:diseaseCause.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding:diseaseNature.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding:diseaseLocation.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding:diseaseTrend.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding:syndromeType.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
Differential View
This structure is derived from ClinicalImpression
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| ClinicalImpression |
ClinicalImpression | |||
| status |
1..1 | code | in-progress | completed | entered-in-error Required Pattern: completed (extensions allowed) | |
| subject |
1..1 | Reference(病人資料(Patient TWCM)) | Patient or group assessed | |
| encounter |
0..1 | Reference(就醫事件(Encounter TWCM)) | Encounter created as part of | |
| effective[x] |
0..1 | dateTime, Period | Time of assessment | |
| assessor |
0..1 | Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole) | The clinician performing the assessment | |
| problem |
0..* | Reference(病情、問題或診斷(ConditionDiagnosis TWCM) | 病人主訴(ConditionChiefComplaint TWCM) | 過敏或不耐症(AllergyIntolerance TWCM)) | Relevant impressions of patient state | |
| Slices for investigation |
0..* | BackboneElement | 四診紀錄。依望、聞、問、切分別參照對應的Observation Slice: Unordered, Open by pattern:code Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| investigation:inspection |
0..1 | BackboneElement | 望診 | |
| code |
1..1 | CodeableConcept | A name/code for the set Required Pattern: | |
| item |
1..1 | Reference(望診(ObservationInspection TWCM)) | Record of a specific investigation | |
| investigation:listeningSmelling |
0..1 | BackboneElement | 聞診 | |
| code |
1..1 | CodeableConcept | A name/code for the set Required Pattern: | |
| item |
1..1 | Reference(聞診(ObservationListeningSmelling TWCM)) | Record of a specific investigation | |
| investigation:inquiry |
0..1 | BackboneElement | 問診 | |
| code |
1..1 | CodeableConcept | A name/code for the set Required Pattern: | |
| item |
1..1 | Reference(問診(ObservationInquiry TWCM)) | Record of a specific investigation | |
| investigation:palpation |
0..1 | BackboneElement | 切診 | |
| code |
1..1 | CodeableConcept | A name/code for the set Required Pattern: | |
| item |
1..1 | Reference(切診(ObservationPalpation TWCM)) | Record of a specific investigation | |
| summary |
1..1 | string | [應填入中醫門診單之望聞問切客觀描述Description] | |
| Slices for finding |
0..* | BackboneElement | 辨證結果。病因、病性、病位、病勢以固定文字標示項目，內容填於basis；證型以itemReference參照ConditionSyndromeTypeTWCM Slice: Unordered, Open by value:itemCodeableConcept.text Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| finding:diseaseCause |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |
| itemCodeableConcept |
1..1 | CodeableConcept | What was found | |
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病因 (no extensions allowed) | |
| basis |
1..1 | string | [應填入中醫門診單之病因Disease Cause] | |
| finding:diseaseNature |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |
| itemCodeableConcept |
1..1 | CodeableConcept | What was found | |
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病性 (no extensions allowed) | |
| basis |
1..1 | string | [應填入中醫門診單之病性Disease Nature] | |
| finding:diseaseLocation |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |
| itemCodeableConcept |
1..1 | CodeableConcept | What was found | |
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病位 (no extensions allowed) | |
| basis |
1..1 | string | [應填入中醫門診單之病位Disease Location] | |
| finding:diseaseTrend |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |
| itemCodeableConcept |
1..1 | CodeableConcept | What was found | |
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病勢 (no extensions allowed) | |
| basis |
1..1 | string | [應填入中醫門診單之病勢Disease Trend] | |
| finding:syndromeType |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |
| itemCodeableConcept |
1..1 | CodeableConcept | What was found | |
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 證型 (no extensions allowed) | |
| itemReference |
1..1 | Reference(病人證型(ConditionSyndromeType TWCM)) | 參照本次辨證所得之病人證型 | |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| ClinicalImpression |
0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
0..1 | Meta | Metadata about the resource | |||||
| implicitRules |
0..1 | uri | A set of rules under which this content was created | |||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
| identifier |
0..* | Identifier | Business identifier | |||||
| status |
1..1 | code | in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. Required Pattern: completed (extensions allowed) | |||||
| statusReason |
0..1 | CodeableConcept | Reason for current status Binding Description: (example): Codes identifying the reason for the current state of a clinical impression. | |||||
| code |
0..1 | CodeableConcept | Kind of assessment performed Binding Description: (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed. | |||||
| description |
0..1 | string | Why/how the assessment was performed | |||||
| subject |
1..1 | Reference(病人資料(Patient TWCM)) | Patient or group assessed | |||||
| encounter |
0..1 | Reference(就醫事件(Encounter TWCM)) | Encounter created as part of | |||||
| effective[x] |
0..1 | Time of assessment | ||||||
| effectiveDateTime |
dateTime | |||||||
| effectivePeriod |
Period | |||||||
| date |
0..1 | dateTime | When the assessment was documented | |||||
| assessor |
0..1 | Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole) | The clinician performing the assessment | |||||
| previous |
0..1 | Reference(ClinicalImpression) | Reference to last assessment | |||||
| problem |
0..* | Reference(病情、問題或診斷(ConditionDiagnosis TWCM) | 病人主訴(ConditionChiefComplaint TWCM) | 過敏或不耐症(AllergyIntolerance TWCM)) | Relevant impressions of patient state | |||||
| Slices for investigation |
0..* | BackboneElement | 四診紀錄。依望、聞、問、切分別參照對應的Observation Slice: Unordered, Open by pattern:code Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| investigation:All Slices |
Content/Rules for all slices | |||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| code |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. | |||||
| item |
0..* | Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media) | Record of a specific investigation | |||||
| investigation:inspection |
0..1 | BackboneElement | 望診 | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| code |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. Required Pattern: | |||||
| item |
1..1 | Reference(望診(ObservationInspection TWCM)) | Record of a specific investigation | |||||
| investigation:listeningSmelling |
0..1 | BackboneElement | 聞診 | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| code |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. Required Pattern: | |||||
| item |
1..1 | Reference(聞診(ObservationListeningSmelling TWCM)) | Record of a specific investigation | |||||
| investigation:inquiry |
0..1 | BackboneElement | 問診 | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| code |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. Required Pattern: | |||||
| item |
1..1 | Reference(問診(ObservationInquiry TWCM)) | Record of a specific investigation | |||||
| investigation:palpation |
0..1 | BackboneElement | 切診 | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| code |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. Required Pattern: | |||||
| item |
1..1 | Reference(切診(ObservationPalpation TWCM)) | Record of a specific investigation | |||||
| protocol |
0..* | uri | Clinical Protocol followed | |||||
| summary |
1..1 | string | [應填入中醫門診單之望聞問切客觀描述Description] | |||||
| Slices for finding |
0..* | BackboneElement | 辨證結果。病因、病性、病位、病勢以固定文字標示項目，內容填於basis；證型以itemReference參照ConditionSyndromeTypeTWCM Slice: Unordered, Open by value:itemCodeableConcept.text Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| finding:All Slices |
Content/Rules for all slices | |||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| itemCodeableConcept |
0..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |||||
| itemReference |
0..1 | Reference(Condition | Observation | Media) | What was found | |||||
| basis |
0..1 | string | Which investigations support finding | |||||
| finding:diseaseCause |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| itemCodeableConcept |
1..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
0..* | Coding | Code defined by a terminology system | |||||
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病因 (no extensions allowed) | |||||
| itemReference |
0..1 | Reference(Condition | Observation | Media) | What was found | |||||
| basis |
1..1 | string | [應填入中醫門診單之病因Disease Cause] | |||||
| finding:diseaseNature |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| itemCodeableConcept |
1..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
0..* | Coding | Code defined by a terminology system | |||||
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病性 (no extensions allowed) | |||||
| itemReference |
0..1 | Reference(Condition | Observation | Media) | What was found | |||||
| basis |
1..1 | string | [應填入中醫門診單之病性Disease Nature] | |||||
| finding:diseaseLocation |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| itemCodeableConcept |
1..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
0..* | Coding | Code defined by a terminology system | |||||
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病位 (no extensions allowed) | |||||
| itemReference |
0..1 | Reference(Condition | Observation | Media) | What was found | |||||
| basis |
1..1 | string | [應填入中醫門診單之病位Disease Location] | |||||
| finding:diseaseTrend |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| itemCodeableConcept |
1..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
0..* | Coding | Code defined by a terminology system | |||||
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 病勢 (no extensions allowed) | |||||
| itemReference |
0..1 | Reference(Condition | Observation | Media) | What was found | |||||
| basis |
1..1 | string | [應填入中醫門診單之病勢Disease Trend] | |||||
| finding:syndromeType |
0..1 | BackboneElement | Possible or likely findings and diagnoses | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| itemCodeableConcept |
1..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
0..* | Coding | Code defined by a terminology system | |||||
| text |
1..1 | string | Plain text representation of the concept Fixed Value: 證型 (no extensions allowed) | |||||
| itemReference |
1..1 | Reference(病人證型(ConditionSyndromeType TWCM)) | 參照本次辨證所得之病人證型 | |||||
| basis |
0..1 | string | Which investigations support finding | |||||
| prognosisCodeableConcept |
0..* | CodeableConcept | Estimate of likely outcome Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings. | |||||
| prognosisReference |
0..* | Reference(RiskAssessment) | RiskAssessment expressing likely outcome | |||||
| supportingInfo |
0..* | Reference(Resource) | Information supporting the clinical impression | |||||
| note |
0..* | Annotation | Comments made about the ClinicalImpression | |||||
| Documentation for this format | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| ClinicalImpression.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.status | Base | required | Clinical Impression Status | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.statusReason | Base | example | Not State | Unknown | |
| ClinicalImpression.code | Base | example | Not State | Unknown | |
| ClinicalImpression.investigation.code | Base | example | Investigation Type | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.investigation:inspection.code | Base | example | Investigation Type | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.investigation:listeningSmelling.code | Base | example | Investigation Type | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.investigation:inquiry.code | Base | example | Investigation Type | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.investigation:palpation.code | Base | example | Investigation Type | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding:diseaseCause.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding:diseaseNature.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding:diseaseLocation.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding:diseaseTrend.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.finding:syndromeType.itemCodeableConcept | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| ClinicalImpression.prognosisCodeableConcept | Base | example | Clinical Impression Prognosis | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
This structure is derived from ClinicalImpression
Summary
Mandatory: 1 element(19 nested mandatory elements)
Must-Support: 29 elements
Fixed: 5 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron