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

Resource Profile: 中醫辨證評估(ClinicalImpression TWCM)

Official URL: https://www.nricm.edu.tw/twcm/StructureDefinition/clinicalimpression-twcm Version: 0.1.0
Draft as of 2026-10-05 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

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!Σ 1..1 code in-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
Required Pattern: completed
... encounter SΣ 0..1 Reference(就醫事件(Encounter TWCM)) Encounter created as part of
... effective[x] SΣ 0..1 Time of assessment
.... effectiveDateTime dateTime
.... effectivePeriod Period
... assessor Σ 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 Σ 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 S 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
.... investigation:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 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 S 0..1 BackboneElement 望診
..... modifierExtension ?!Σ 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: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 118243007
....... display 1..1 string Representation defined by the system
Fixed Value: Finding by inspection (simple observation)
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... item S 1..1 Reference(望診(ObservationInspection TWCM)) Record of a specific investigation
.... investigation:listeningSmelling S 0..1 BackboneElement 聞診
..... modifierExtension ?!Σ 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: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 118241009
....... display 1..1 string Representation defined by the system
Fixed Value: Finding by auscultation
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... item S 1..1 Reference(聞診(ObservationListeningSmelling TWCM)) Record of a specific investigation
.... investigation:inquiry S 0..1 BackboneElement 問診
..... modifierExtension ?!Σ 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: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 418799008
....... display 1..1 string Representation defined by the system
Fixed Value: Finding reported by subject or history provider
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... item S 1..1 Reference(問診(ObservationInquiry TWCM)) Record of a specific investigation
.... investigation:palpation S 0..1 BackboneElement 切診
..... modifierExtension ?!Σ 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: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 118242002
....... display 1..1 string Representation defined by the system
Fixed Value: Finding by palpation
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... item S 1..1 Reference(切診(ObservationPalpation TWCM)) Record of a specific investigation
... summary S 1..1 string [應填入中醫門診單之望聞問切客觀描述Description]
... Slices for finding S 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
.... finding:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... finding:diseaseCause S 0..1 BackboneElement Possible or likely findings and diagnoses
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... itemCodeableConcept S 1..1 CodeableConcept What was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.
...... text Σ 1..1 string Plain text representation of the concept
Fixed Value: 病因
..... basis S 1..1 string [應填入中醫門診單之病因Disease Cause]
.... finding:diseaseNature S 0..1 BackboneElement Possible or likely findings and diagnoses
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... itemCodeableConcept S 1..1 CodeableConcept What was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.
...... text Σ 1..1 string Plain text representation of the concept
Fixed Value: 病性
..... basis S 1..1 string [應填入中醫門診單之病性Disease Nature]
.... finding:diseaseLocation S 0..1 BackboneElement Possible or likely findings and diagnoses
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... itemCodeableConcept S 1..1 CodeableConcept What was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.
...... text Σ 1..1 string Plain text representation of the concept
Fixed Value: 病位
..... basis S 1..1 string [應填入中醫門診單之病位Disease Location]
.... finding:diseaseTrend S 0..1 BackboneElement Possible or likely findings and diagnoses
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... itemCodeableConcept S 1..1 CodeableConcept What was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.
...... text Σ 1..1 string Plain text representation of the concept
Fixed Value: 病勢
..... basis S 1..1 string [應填入中醫門診單之病勢Disease Trend]
.... finding:syndromeType S 0..1 BackboneElement Possible or likely findings and diagnoses
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... itemCodeableConcept S 1..1 CodeableConcept What was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.
...... text Σ 1..1 string Plain text representation of the concept
Fixed Value: 證型
..... itemReference S 1..1 Reference(病人證型(ConditionSyndromeType TWCM)) 參照本次辨證所得之病人證型

doco Documentation for this format

Terminology Bindings

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.

Constraints

Id Grade Path(s) Description Expression

This structure is derived from ClinicalImpression

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression ClinicalImpression
... status 1..1 code in-progress | completed | entered-in-error
Required Pattern: completed
... subject S 1..1 Reference(病人資料(Patient TWCM)) Patient or group assessed
... encounter S 0..1 Reference(就醫事件(Encounter TWCM)) Encounter created as part of
... 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 S 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
.... investigation:inspection S 0..1 BackboneElement 望診
..... code 1..1 CodeableConcept A name/code for the set
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 118243007
....... display 1..1 string Representation defined by the system
Fixed Value: Finding by inspection (simple observation)
..... item S 1..1 Reference(望診(ObservationInspection TWCM)) Record of a specific investigation
.... investigation:listeningSmelling S 0..1 BackboneElement 聞診
..... code 1..1 CodeableConcept A name/code for the set
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 118241009
....... display 1..1 string Representation defined by the system
Fixed Value: Finding by auscultation
..... item S 1..1 Reference(聞診(ObservationListeningSmelling TWCM)) Record of a specific investigation
.... investigation:inquiry S 0..1 BackboneElement 問診
..... code 1..1 CodeableConcept A name/code for the set
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 418799008
....... display 1..1 string Representation defined by the system
Fixed Value: Finding reported by subject or history provider
..... item S 1..1 Reference(問診(ObservationInquiry TWCM)) Record of a specific investigation
.... investigation:palpation S 0..1 BackboneElement 切診
..... code 1..1 CodeableConcept A name/code for the set
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 118242002
....... display 1..1 string Representation defined by the system
Fixed Value: Finding by palpation
..... item S 1..1 Reference(切診(ObservationPalpation TWCM)) Record of a specific investigation
... summary S 1..1 string [應填入中醫門診單之望聞問切客觀描述Description]
... Slices for finding S 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
.... finding:diseaseCause S 0..1 BackboneElement Possible or likely findings and diagnoses
..... itemCodeableConcept S 1..1 CodeableConcept What was found
...... text 1..1 string Plain text representation of the concept
Fixed Value: 病因
..... basis S 1..1 string [應填入中醫門診單之病因Disease Cause]
.... finding:diseaseNature S 0..1 BackboneElement Possible or likely findings and diagnoses
..... itemCodeableConcept S 1..1 CodeableConcept What was found
...... text 1..1 string Plain text representation of the concept
Fixed Value: 病性
..... basis S 1..1 string [應填入中醫門診單之病性Disease Nature]
.... finding:diseaseLocation S 0..1 BackboneElement Possible or likely findings and diagnoses
..... itemCodeableConcept S 1..1 CodeableConcept What was found
...... text 1..1 string Plain text representation of the concept
Fixed Value: 病位
..... basis S 1..1 string [應填入中醫門診單之病位Disease Location]
.... finding:diseaseTrend S 0..1 BackboneElement Possible or likely findings and diagnoses
..... itemCodeableConcept S 1..1 CodeableConcept What was found
...... text 1..1 string Plain text representation of the concept
Fixed Value: 病勢
..... basis S 1..1 string [應填入中醫門診單之病勢Disease Trend]
.... finding:syndromeType S 0..1 BackboneElement Possible or likely findings and diagnoses
..... itemCodeableConcept S 1..1 CodeableConcept What was found
...... text 1..1 string Plain text representation of the concept
Fixed Value: 證型
..... itemReference S 1..1 Reference(病人證型(ConditionSyndromeType TWCM)) 參照本次辨證所得之病人證型

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 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.
Additional BindingsPurpose
AllLanguages Max Binding
... 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 Σ 0..* Identifier Business identifier
... status ?!Σ 1..1 code in-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
Required Pattern: completed
... statusReason 0..1 CodeableConcept Reason for current status
Binding Description: (example): Codes identifying the reason for the current state of a clinical impression.
... code Σ 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 Σ 0..1 string Why/how the assessment was performed
... subject SΣ 1..1 Reference(病人資料(Patient TWCM)) Patient or group assessed
... encounter SΣ 0..1 Reference(就醫事件(Encounter TWCM)) Encounter created as part of
... effective[x] SΣ 0..1 Time of assessment
.... effectiveDateTime dateTime
.... effectivePeriod Period
... date Σ 0..1 dateTime When the assessment was documented
... assessor Σ 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 Σ 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 S 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
.... 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 ?!Σ 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 S 0..1 BackboneElement 望診
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 1..1 CodeableConcept A name/code for the set
Binding: InvestigationType (example): A name/code for a set of investigations.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 118243007
....... display 1..1 string Representation defined by the system
Fixed Value: Finding by inspection (simple observation)
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... item S 1..1 Reference(望診(ObservationInspection TWCM)) Record of a specific investigation
.... investigation:listeningSmelling S 0..1 BackboneElement 聞診
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 1..1 CodeableConcept A name/code for the set
Binding: InvestigationType (example): A name/code for a set of investigations.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 118241009
....... display 1..1 string Representation defined by the system
Fixed Value: Finding by auscultation
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... item S 1..1 Reference(聞診(ObservationListeningSmelling TWCM)) Record of a specific investigation
.... investigation:inquiry S 0..1 BackboneElement 問診
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 1..1 CodeableConcept A name/code for the set
Binding: InvestigationType (example): A name/code for a set of investigations.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 418799008
....... display 1..1 string Representation defined by the system
Fixed Value: Finding reported by subject or history provider
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... item S 1..1 Reference(問診(ObservationInquiry TWCM)) Record of a specific investigation
.... investigation:palpation S 0..1 BackboneElement 切診
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 1..1 CodeableConcept A name/code for the set
Binding: InvestigationType (example): A name/code for a set of investigations.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 118242002
....... display 1..1 string Representation defined by the system
Fixed Value: Finding by palpation
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... item S 1..1 Reference(切診(ObservationPalpation TWCM)) Record of a specific investigation
... protocol 0..* uri Clinical Protocol followed
... summary S 1..1 string [應填入中醫門診單之望聞問切客觀描述Description]
... Slices for finding S 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
.... 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 ?!Σ 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 S 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 ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... itemCodeableConcept S 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 Σ 0..* Coding Code defined by a terminology system
...... text Σ 1..1 string Plain text representation of the concept
Fixed Value: 病因
..... itemReference 0..1 Reference(Condition | Observation | Media) What was found
..... basis S 1..1 string [應填入中醫門診單之病因Disease Cause]
.... finding:diseaseNature S 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 ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... itemCodeableConcept S 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 Σ 0..* Coding Code defined by a terminology system
...... text Σ 1..1 string Plain text representation of the concept
Fixed Value: 病性
..... itemReference 0..1 Reference(Condition | Observation | Media) What was found
..... basis S 1..1 string [應填入中醫門診單之病性Disease Nature]
.... finding:diseaseLocation S 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 ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... itemCodeableConcept S 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 Σ 0..* Coding Code defined by a terminology system
...... text Σ 1..1 string Plain text representation of the concept
Fixed Value: 病位
..... itemReference 0..1 Reference(Condition | Observation | Media) What was found
..... basis S 1..1 string [應填入中醫門診單之病位Disease Location]
.... finding:diseaseTrend S 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 ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... itemCodeableConcept S 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 Σ 0..* Coding Code defined by a terminology system
...... text Σ 1..1 string Plain text representation of the concept
Fixed Value: 病勢
..... itemReference 0..1 Reference(Condition | Observation | Media) What was found
..... basis S 1..1 string [應填入中醫門診單之病勢Disease Trend]
.... finding:syndromeType S 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 ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... itemCodeableConcept S 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 Σ 0..* Coding Code defined by a terminology system
...... text Σ 1..1 string Plain text representation of the concept
Fixed Value: 證型
..... itemReference S 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

doco Documentation for this format

Terminology Bindings

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.

Constraints

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:

  • The element 1 is sliced based on the value of ClinicalImpression.investigation
  • The element 1 is sliced based on the value of ClinicalImpression.finding

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!Σ 1..1 code in-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
Required Pattern: completed
... encounter SΣ 0..1 Reference(就醫事件(Encounter TWCM)) Encounter created as part of
... effective[x] SΣ 0..1 Time of assessment
.... effectiveDateTime dateTime
.... effectivePeriod Period
... assessor Σ 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 Σ 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 S 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
.... investigation:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 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 S 0..1 BackboneElement 望診
..... modifierExtension ?!Σ 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: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 118243007
....... display 1..1 string Representation defined by the system
Fixed Value: Finding by inspection (simple observation)
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... item S 1..1 Reference(望診(ObservationInspection TWCM)) Record of a specific investigation
.... investigation:listeningSmelling S 0..1 BackboneElement 聞診
..... modifierExtension ?!Σ 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: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 118241009
....... display 1..1 string Representation defined by the system
Fixed Value: Finding by auscultation
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... item S 1..1 Reference(聞診(ObservationListeningSmelling TWCM)) Record of a specific investigation
.... investigation:inquiry S 0..1 BackboneElement 問診
..... modifierExtension ?!Σ 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: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 418799008
....... display 1..1 string Representation defined by the system
Fixed Value: Finding reported by subject or history provider
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... item S 1..1 Reference(問診(ObservationInquiry TWCM)) Record of a specific investigation
.... investigation:palpation S 0..1 BackboneElement 切診
..... modifierExtension ?!Σ 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: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 118242002
....... display 1..1 string Representation defined by the system
Fixed Value: Finding by palpation
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... item S 1..1 Reference(切診(ObservationPalpation TWCM)) Record of a specific investigation
... summary S 1..1 string [應填入中醫門診單之望聞問切客觀描述Description]
... Slices for finding S 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
.... finding:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... finding:diseaseCause S 0..1 BackboneElement Possible or likely findings and diagnoses
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... itemCodeableConcept S 1..1 CodeableConcept What was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.
...... text Σ 1..1 string Plain text representation of the concept
Fixed Value: 病因
..... basis S 1..1 string [應填入中醫門診單之病因Disease Cause]
.... finding:diseaseNature S 0..1 BackboneElement Possible or likely findings and diagnoses
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... itemCodeableConcept S 1..1 CodeableConcept What was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.
...... text Σ 1..1 string Plain text representation of the concept
Fixed Value: 病性
..... basis S 1..1 string [應填入中醫門診單之病性Disease Nature]
.... finding:diseaseLocation S 0..1 BackboneElement Possible or likely findings and diagnoses
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... itemCodeableConcept S 1..1 CodeableConcept What was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.
...... text Σ 1..1 string Plain text representation of the concept
Fixed Value: 病位
..... basis S 1..1 string [應填入中醫門診單之病位Disease Location]
.... finding:diseaseTrend S 0..1 BackboneElement Possible or likely findings and diagnoses
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... itemCodeableConcept S 1..1 CodeableConcept What was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.
...... text Σ 1..1 string Plain text representation of the concept
Fixed Value: 病勢
..... basis S 1..1 string [應填入中醫門診單之病勢Disease Trend]
.... finding:syndromeType S 0..1 BackboneElement Possible or likely findings and diagnoses
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... itemCodeableConcept S 1..1 CodeableConcept What was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.
...... text Σ 1..1 string Plain text representation of the concept
Fixed Value: 證型
..... itemReference S 1..1 Reference(病人證型(ConditionSyndromeType TWCM)) 參照本次辨證所得之病人證型

doco Documentation for this format

Terminology Bindings

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.

Constraints

Id Grade Path(s) Description Expression

Differential View

This structure is derived from ClinicalImpression

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression ClinicalImpression
... status 1..1 code in-progress | completed | entered-in-error
Required Pattern: completed
... subject S 1..1 Reference(病人資料(Patient TWCM)) Patient or group assessed
... encounter S 0..1 Reference(就醫事件(Encounter TWCM)) Encounter created as part of
... 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 S 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
.... investigation:inspection S 0..1 BackboneElement 望診
..... code 1..1 CodeableConcept A name/code for the set
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 118243007
....... display 1..1 string Representation defined by the system
Fixed Value: Finding by inspection (simple observation)
..... item S 1..1 Reference(望診(ObservationInspection TWCM)) Record of a specific investigation
.... investigation:listeningSmelling S 0..1 BackboneElement 聞診
..... code 1..1 CodeableConcept A name/code for the set
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 118241009
....... display 1..1 string Representation defined by the system
Fixed Value: Finding by auscultation
..... item S 1..1 Reference(聞診(ObservationListeningSmelling TWCM)) Record of a specific investigation
.... investigation:inquiry S 0..1 BackboneElement 問診
..... code 1..1 CodeableConcept A name/code for the set
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 418799008
....... display 1..1 string Representation defined by the system
Fixed Value: Finding reported by subject or history provider
..... item S 1..1 Reference(問診(ObservationInquiry TWCM)) Record of a specific investigation
.... investigation:palpation S 0..1 BackboneElement 切診
..... code 1..1 CodeableConcept A name/code for the set
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 118242002
....... display 1..1 string Representation defined by the system
Fixed Value: Finding by palpation
..... item S 1..1 Reference(切診(ObservationPalpation TWCM)) Record of a specific investigation
... summary S 1..1 string [應填入中醫門診單之望聞問切客觀描述Description]
... Slices for finding S 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
.... finding:diseaseCause S 0..1 BackboneElement Possible or likely findings and diagnoses
..... itemCodeableConcept S 1..1 CodeableConcept What was found
...... text 1..1 string Plain text representation of the concept
Fixed Value: 病因
..... basis S 1..1 string [應填入中醫門診單之病因Disease Cause]
.... finding:diseaseNature S 0..1 BackboneElement Possible or likely findings and diagnoses
..... itemCodeableConcept S 1..1 CodeableConcept What was found
...... text 1..1 string Plain text representation of the concept
Fixed Value: 病性
..... basis S 1..1 string [應填入中醫門診單之病性Disease Nature]
.... finding:diseaseLocation S 0..1 BackboneElement Possible or likely findings and diagnoses
..... itemCodeableConcept S 1..1 CodeableConcept What was found
...... text 1..1 string Plain text representation of the concept
Fixed Value: 病位
..... basis S 1..1 string [應填入中醫門診單之病位Disease Location]
.... finding:diseaseTrend S 0..1 BackboneElement Possible or likely findings and diagnoses
..... itemCodeableConcept S 1..1 CodeableConcept What was found
...... text 1..1 string Plain text representation of the concept
Fixed Value: 病勢
..... basis S 1..1 string [應填入中醫門診單之病勢Disease Trend]
.... finding:syndromeType S 0..1 BackboneElement Possible or likely findings and diagnoses
..... itemCodeableConcept S 1..1 CodeableConcept What was found
...... text 1..1 string Plain text representation of the concept
Fixed Value: 證型
..... itemReference S 1..1 Reference(病人證型(ConditionSyndromeType TWCM)) 參照本次辨證所得之病人證型

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 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.
Additional BindingsPurpose
AllLanguages Max Binding
... 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 Σ 0..* Identifier Business identifier
... status ?!Σ 1..1 code in-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
Required Pattern: completed
... statusReason 0..1 CodeableConcept Reason for current status
Binding Description: (example): Codes identifying the reason for the current state of a clinical impression.
... code Σ 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 Σ 0..1 string Why/how the assessment was performed
... subject SΣ 1..1 Reference(病人資料(Patient TWCM)) Patient or group assessed
... encounter SΣ 0..1 Reference(就醫事件(Encounter TWCM)) Encounter created as part of
... effective[x] SΣ 0..1 Time of assessment
.... effectiveDateTime dateTime
.... effectivePeriod Period
... date Σ 0..1 dateTime When the assessment was documented
... assessor Σ 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 Σ 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 S 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
.... 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 ?!Σ 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 S 0..1 BackboneElement 望診
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 1..1 CodeableConcept A name/code for the set
Binding: InvestigationType (example): A name/code for a set of investigations.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 118243007
....... display 1..1 string Representation defined by the system
Fixed Value: Finding by inspection (simple observation)
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... item S 1..1 Reference(望診(ObservationInspection TWCM)) Record of a specific investigation
.... investigation:listeningSmelling S 0..1 BackboneElement 聞診
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 1..1 CodeableConcept A name/code for the set
Binding: InvestigationType (example): A name/code for a set of investigations.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 118241009
....... display 1..1 string Representation defined by the system
Fixed Value: Finding by auscultation
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... item S 1..1 Reference(聞診(ObservationListeningSmelling TWCM)) Record of a specific investigation
.... investigation:inquiry S 0..1 BackboneElement 問診
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 1..1 CodeableConcept A name/code for the set
Binding: InvestigationType (example): A name/code for a set of investigations.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 418799008
....... display 1..1 string Representation defined by the system
Fixed Value: Finding reported by subject or history provider
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... item S 1..1 Reference(問診(ObservationInquiry TWCM)) Record of a specific investigation
.... investigation:palpation S 0..1 BackboneElement 切診
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 1..1 CodeableConcept A name/code for the set
Binding: InvestigationType (example): A name/code for a set of investigations.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 118242002
....... display 1..1 string Representation defined by the system
Fixed Value: Finding by palpation
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... item S 1..1 Reference(切診(ObservationPalpation TWCM)) Record of a specific investigation
... protocol 0..* uri Clinical Protocol followed
... summary S 1..1 string [應填入中醫門診單之望聞問切客觀描述Description]
... Slices for finding S 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
.... 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 ?!Σ 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 S 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 ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... itemCodeableConcept S 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 Σ 0..* Coding Code defined by a terminology system
...... text Σ 1..1 string Plain text representation of the concept
Fixed Value: 病因
..... itemReference 0..1 Reference(Condition | Observation | Media) What was found
..... basis S 1..1 string [應填入中醫門診單之病因Disease Cause]
.... finding:diseaseNature S 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 ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... itemCodeableConcept S 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 Σ 0..* Coding Code defined by a terminology system
...... text Σ 1..1 string Plain text representation of the concept
Fixed Value: 病性
..... itemReference 0..1 Reference(Condition | Observation | Media) What was found
..... basis S 1..1 string [應填入中醫門診單之病性Disease Nature]
.... finding:diseaseLocation S 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 ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... itemCodeableConcept S 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 Σ 0..* Coding Code defined by a terminology system
...... text Σ 1..1 string Plain text representation of the concept
Fixed Value: 病位
..... itemReference 0..1 Reference(Condition | Observation | Media) What was found
..... basis S 1..1 string [應填入中醫門診單之病位Disease Location]
.... finding:diseaseTrend S 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 ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... itemCodeableConcept S 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 Σ 0..* Coding Code defined by a terminology system
...... text Σ 1..1 string Plain text representation of the concept
Fixed Value: 病勢
..... itemReference 0..1 Reference(Condition | Observation | Media) What was found
..... basis S 1..1 string [應填入中醫門診單之病勢Disease Trend]
.... finding:syndromeType S 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 ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... itemCodeableConcept S 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 Σ 0..* Coding Code defined by a terminology system
...... text Σ 1..1 string Plain text representation of the concept
Fixed Value: 證型
..... itemReference S 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

doco Documentation for this format

Terminology Bindings

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.

Constraints

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:

  • The element 1 is sliced based on the value of ClinicalImpression.investigation
  • The element 1 is sliced based on the value of ClinicalImpression.finding

 

Other representations of profile: CSV, Excel, Schematron