Generated Narrative: StructureDefinition composition-twcm Name Flags Card. Type Description & Constraints Composition <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R4/conformance-rules.html#constraints" title="This element has or is affected by constraints ( majorIllness-condition-twcm )">C 0..* TWCoreComposition 將一組resources組成一份連貫的臨床聲明，並附有臨床證明。 Constraints: majorIllness-condition-twcm #xD; meta S 1..1 Meta 應填入於中醫門診單之病歷表單版本號Sheet Version #xD; versionId S 1..1 id Version specific identifier #xD; identifier 1..1 Identifier 不分版本的臨床文件架構(Composition)識別碼。[應填入於中醫門診單之病歷表單編號] #xD; type 1..1 CodeableConcept Description of identifier Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: SNO #xD; value 1..1 string The value that is unique #xD; assigner 0..1 Reference(TW Core Organization) Organization that issued id (may be just text) #xD; status 1..1 code registered | partial | preliminary | final | amended | corrected + Required Pattern: final #xD; type 1..1 CodeableConceptTW Composition的種類（如果可能請使用LOINC） Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 34108-1 #xD; display 1..1 string Representation defined by the system Fixed Value: Outpatient Note #xD; subject 0..1 Reference(病人資料(Patient TWCM)) Composition是關於誰和/或什麼 #xD; reference S 1..1 string Literal reference, Relative, internal or absolute URL #xD; encounter S 0..1 Reference(就醫事件(Encounter TWCM)) Composition的情境 #xD; reference S 1..1 string Literal reference, Relative, internal or absolute URL #xD; date 1..1 dateTime [應填入文件產生時間Create Time] #xD; author 1..* Reference(醫事機構(Organization TWCM)) 誰和/或什麼創建了這個Composition #xD; reference S 1..1 string Literal reference, Relative, internal or absolute URL #xD; title 1..1 string 固定值。[應填入病歷表單名稱Sheet Name] Fixed Value: 中醫門診單 #xD; confidentiality S 1..1 code [應填入文件敏感性Doc Confidentiality Code] #xD; attester #xD; party 0..1 Reference(病人資料(Patient TWCM) | TW Core RelatedPerson | 健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole | 醫事機構(Organization TWCM)) 誰證明了此Composition #xD; custodian 0..1 Reference(醫事機構(Organization TWCM)) 維護Composition的機構 #xD; relatesTo #xD; target[x] 1..1 此關係的目標文件 #xD; targetIdentifier Identifier #xD; targetReference Reference(中醫-臨床文件架構(Composition TWCM)) #xD; Slices for section 6..* BackboneElement Composition被分成一個或數個小節 Slice: Unordered, Open by value:code #xD; section:All Slices Content/Rules for all slices #xD; author 0..* Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole | 醫事機構(Organization TWCM) | 病人資料(Patient TWCM) | TW Core Implantable Device | TW Core RelatedPerson) 誰和/或什麼人撰寫了該小節 #xD; section:PatientInformation S 0..1 BackboneElement Composition被分成一個或數個小節 #xD; title 1..1 string 小節標籤(例如：目錄ToC) #xD; code 1..1 CodeableConceptTW 小節分類(建議) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 52460-3 #xD; display 1..1 string Representation defined by the system Fixed Value: Patient Information #xD; author 0..* Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole | 醫事機構(Organization TWCM) | 病人資料(Patient TWCM) | TW Core Implantable Device | TW Core RelatedPerson) 誰和/或什麼人撰寫了該小節 #xD; Slices for section 0..3 嵌套的小節 Slice: Unordered, Open by profile:entry.resolve() #xD; Slices for section Content/Rules for all slices #xD; section:educationlevel 0..1 BackboneElement 嵌套的小節 #xD; code 0..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 80913-7 #xD; display 1..1 string Representation defined by the system Fixed Value: Highest level of education [US Standard Certificate of Death] #xD; entry 0..* Reference(教育程度(ObservationEducationLevel TWCM)) A reference to data that supports this section #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:occupation 0..1 BackboneElement 嵌套的小節 #xD; code 0..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 85658-3 #xD; display 1..1 string Representation defined by the system Fixed Value: Occupation [Type] #xD; entry 0..* Reference(職業(ObservationOccupation TWCM)) A reference to data that supports this section #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:bloodtype 0..1 BackboneElement 嵌套的小節 #xD; code 0..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 882-1 #xD; display 1..1 string Representation defined by the system Fixed Value: ABO and Rh group [Type] in Blood #xD; entry 0..* Reference(血型(ObservationBloodtype TWCM)) A reference to data that supports this section #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:AllergyIntolerance S 0..1 BackboneElement Composition被分成一個或數個小節 #xD; title 1..1 string 小節標籤(例如：目錄ToC) #xD; code 1..1 CodeableConceptTW 小節分類(建議) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 48765-2 #xD; display 1..1 string Representation defined by the system Fixed Value: Allergies and adverse reactions Document #xD; author 0..* Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole | 醫事機構(Organization TWCM) | 病人資料(Patient TWCM) | TW Core Implantable Device | TW Core RelatedPerson) 誰和/或什麼人撰寫了該小節 #xD; entry 0..* Reference(過敏或不耐症(AllergyIntolerance TWCM)) 提供一個連結用於參照或查看支持此小節內容的資料 #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:ConditionPastMedicalHistory S 0..1 BackboneElement Composition被分成一個或數個小節 #xD; title 1..1 string 小節標籤(例如：目錄ToC) #xD; code 1..1 CodeableConceptTW 小節分類(建議) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 11348-0 #xD; display 1..1 string Representation defined by the system Fixed Value: History of Past illness note #xD; author 0..* Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole | 醫事機構(Organization TWCM) | 病人資料(Patient TWCM) | TW Core Implantable Device | TW Core RelatedPerson) 誰和/或什麼人撰寫了該小節 #xD; entry 0..* Reference(過去病史(ConditionPastMedicalHistory TWCM)) 提供一個連結用於參照或查看支持此小節內容的資料 #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:ConditionMajorIllness S 1..1 BackboneElement Composition被分成一個或數個小節 #xD; title 1..1 string 小節標籤(例如：目錄ToC) #xD; code 1..1 CodeableConceptTW 小節分類(建議) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 11338-1 #xD; display 1..1 string Representation defined by the system Fixed Value: History of Major illnesses and injuries Narrative #xD; author 0..* Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole | 醫事機構(Organization TWCM) | 病人資料(Patient TWCM) | TW Core Implantable Device | TW Core RelatedPerson) 誰和/或什麼人撰寫了該小節 #xD; entry 1..1 Reference(重大傷病註記(ObservationMajorIllness TWCM)) 提供一個連結用於參照或查看支持此小節內容的資料 #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section 0..* BackboneElement 嵌套的小節 #xD; code 0..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 11338-1 #xD; display 1..1 string Representation defined by the system Fixed Value: History of Major illnesses and injuries Narrative #xD; entry 0..* Reference(重大傷病(ConditionMajorIllness TWCM)) A reference to data that supports this section #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:Medication S 0..1 BackboneElement Composition被分成一個或數個小節 #xD; title 1..1 string 小節標籤(例如：目錄ToC) #xD; code 1..1 CodeableConceptTW 小節分類(建議) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 10160-0 #xD; display 1..1 string Representation defined by the system Fixed Value: History of Medication use Narrative #xD; author 0..* Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole | 醫事機構(Organization TWCM) | 病人資料(Patient TWCM) | TW Core Implantable Device | TW Core RelatedPerson) 誰和/或什麼人撰寫了該小節 #xD; Slices for section 0..* 嵌套的小節 Slice: Unordered, Open by profile:entry.resolve() #xD; Slices for section Content/Rules for all slices #xD; section:medication 0..* BackboneElement 嵌套的小節 #xD; code 0..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 87232-5 #xD; display 1..1 string Representation defined by the system Fixed Value: Medication administration.brief #xD; entry 0..* Reference(藥品(Medication TWCM)) A reference to data that supports this section #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:medicationrequest 0..* BackboneElement 嵌套的小節 #xD; code 0..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 57833-6 #xD; display 1..1 string Representation defined by the system Fixed Value: Prescription for medication #xD; entry 0..* Reference(中醫-藥品請求(MedicationRequest TWCM)) A reference to data that supports this section #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:ConditionDiagnosis S 1..1 BackboneElement Composition被分成一個或數個小節 #xD; title 1..1 string 小節標籤(例如：目錄ToC) #xD; code 1..1 CodeableConceptTW 小節分類(建議) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 11450-4 #xD; display 1..1 string Representation defined by the system Fixed Value: Problem list - Reported #xD; author 0..* Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole | 醫事機構(Organization TWCM) | 病人資料(Patient TWCM) | TW Core Implantable Device | TW Core RelatedPerson) 誰和/或什麼人撰寫了該小節 #xD; Slices for section 3..* 嵌套的小節 Slice: Unordered, Open by profile:entry.resolve() #xD; Slices for section Content/Rules for all slices #xD; section:conditiondiagnosis 1..* BackboneElement 嵌套的小節 #xD; code 0..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 29548-5 #xD; display 1..1 string Representation defined by the system Fixed Value: Diagnosis Narrative #xD; entry 0..* Reference(病情、問題或診斷(ConditionDiagnosis TWCM)) A reference to data that supports this section #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:practitioner 1..1 BackboneElement 嵌套的小節 #xD; code 0..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 18600-7 #xD; display 1..1 string Representation defined by the system Fixed Value: Primary practitioner identifier #xD; entry 0..* Reference(健康照護服務提供人員資料(Practitioner TWCM)) A reference to data that supports this section #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:careplan 1..1 BackboneElement 嵌套的小節 #xD; code 0..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 101541-1 #xD; display 1..1 string Representation defined by the system Fixed Value: Multidisciplinary Comprehensive plan of care note #xD; entry 0..* Reference(關懷計畫(CarePlan TWCM)) A reference to data that supports this section #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:observationtonguecondition 0..1 BackboneElement 嵌套的小節 #xD; code 0..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 29548-5 #xD; display 1..1 string Representation defined by the system Fixed Value: Diagnosis Narrative #xD; entry 0..1 Reference(病人舌象(ObservationTongueCondition TWCM)) A reference to data that supports this section #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:observationpulsecondition 0..1 BackboneElement 嵌套的小節 #xD; code 0..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 29548-5 #xD; display 1..1 string Representation defined by the system Fixed Value: Diagnosis Narrative #xD; entry 0..1 Reference(病人脈象(ObservationPulseCondition TWCM)) A reference to data that supports this section #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:observationsyndrometype 0..1 BackboneElement 嵌套的小節 #xD; code 0..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 29548-5 #xD; display 1..1 string Representation defined by the system Fixed Value: Diagnosis Narrative #xD; entry 0..1 Reference(病人證型(ObservationSyndromeType TWCM)) A reference to data that supports this section #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:observationtherapeuticprinciples 0..1 BackboneElement 嵌套的小節 #xD; code 0..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 29548-5 #xD; display 1..1 string Representation defined by the system Fixed Value: Diagnosis Narrative #xD; entry 0..1 Reference(病人治則(ObservationTherapeuticPrinciples TWCM)) A reference to data that supports this section #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:ConditionChiefComplaint S 1..1 BackboneElement Composition被分成一個或數個小節 #xD; title 1..1 string 小節標籤(例如：目錄ToC) #xD; code 1..1 CodeableConceptTW 小節分類(建議) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 10154-3 #xD; display 1..1 string Representation defined by the system Fixed Value: Chief complaint Narrative - Reported #xD; author 0..* Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole | 醫事機構(Organization TWCM) | 病人資料(Patient TWCM) | TW Core Implantable Device | TW Core RelatedPerson) 誰和/或什麼人撰寫了該小節 #xD; entry 0..* Reference(病人主訴(ConditionChiefComplaint TWCM)) 提供一個連結用於參照或查看支持此小節內容的資料 #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:ObservationVitalSign S 1..1 BackboneElement Composition被分成一個或數個小節 #xD; title 1..1 string 小節標籤(例如：目錄ToC) #xD; code 1..1 CodeableConceptTW 小節分類(建議) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 8716-3 #xD; display 1..1 string Representation defined by the system Fixed Value: Vital signs note #xD; author 0..* Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole | 醫事機構(Organization TWCM) | 病人資料(Patient TWCM) | TW Core Implantable Device | TW Core RelatedPerson) 誰和/或什麼人撰寫了該小節 #xD; entry 0..* Reference(生命徵象(ObservationVitalSigns TWCM)) 提供一個連結用於參照或查看支持此小節內容的資料 #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:Procedure S 1..1 BackboneElement Composition被分成一個或數個小節 #xD; title 1..1 string 小節標籤(例如：目錄ToC) #xD; code 1..1 CodeableConceptTW 小節分類(建議) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 29554-3 #xD; display 1..1 string Representation defined by the system Fixed Value: Procedure Narrative #xD; author 0..* Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole | 醫事機構(Organization TWCM) | 病人資料(Patient TWCM) | TW Core Implantable Device | TW Core RelatedPerson) 誰和/或什麼人撰寫了該小節 #xD; entry 1..* Reference(中醫-處置或手術(Procedure TWCM)) 提供一個連結用於參照或查看支持此小節內容的資料 #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:ObservationLabResults S 0..1 BackboneElement Composition被分成一個或數個小節 #xD; title 1..1 string 小節標籤(例如：目錄ToC) #xD; code 1..1 CodeableConceptTW 小節分類(建議) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 30954-2 #xD; display 1..1 string Representation defined by the system Fixed Value: Relevant diagnostic tests/laboratory data note #xD; author 0..* Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole | 醫事機構(Organization TWCM) | 病人資料(Patient TWCM) | TW Core Implantable Device | TW Core RelatedPerson) 誰和/或什麼人撰寫了該小節 #xD; Slices for section 3..* 嵌套的小節 Slice: Unordered, Open by profile:entry.resolve() #xD; Slices for section Content/Rules for all slices #xD; section:observation 1..* BackboneElement 嵌套的小節 #xD; code 0..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 19146-0 #xD; display 1..1 string Representation defined by the system Fixed Value: Referral lab test results #xD; entry 0..* Reference(檢驗檢查(Observation TWCM)) A reference to data that supports this section #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:servicerequest 1..* BackboneElement 嵌套的小節 #xD; code 0..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 77597-3 #xD; display 1..1 string Representation defined by the system Fixed Value: Orders placed Document #xD; entry 0..* Reference(服務請求(ServiceRequest TWCM)) A reference to data that supports this section #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:diagnosticreport 0..* BackboneElement 嵌套的小節 #xD; code 0..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 50398-7 #xD; display 1..1 string Representation defined by the system Fixed Value: Narrative diagnostic report [Interpretation] #xD; entry 0..* Reference(診斷報告(DiagnosticReport TWCM)) A reference to data that supports this section #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:organizationinspection 1..* BackboneElement 嵌套的小節 #xD; code 0..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 52482-7 #xD; display 1..1 string Representation defined by the system Fixed Value: Laboratory #xD; entry 0..* Reference(檢驗檢查機構(OrganizationInspection TWCM)) A reference to data that supports this section #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; section:DocumentReference S 1..1 BackboneElement Composition被分成一個或數個小節 #xD; title 1..1 string 小節標籤(例如：目錄ToC) #xD; code 1..1 CodeableConceptTW 小節分類(建議) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 75310-3 #xD; display 1..1 string Representation defined by the system Fixed Value: Health concerns Document #xD; author 0..* Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole | 醫事機構(Organization TWCM) | 病人資料(Patient TWCM) | TW Core Implantable Device | TW Core RelatedPerson) 誰和/或什麼人撰寫了該小節 #xD; entry 1..1 Reference(文件參照(DocumentReference TWCM)) 提供一個連結用於參照或查看支持此小節內容的資料 #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; Documentation for this format
此Profile用於描述中醫門診單的報告文件
將一組resources組成一份連貫的臨床聲明，並附有臨床證明。
一組與健康照護相關的資訊，這些訊息被組合成一個單一的邏輯套件，提供一個單一的連貫的意義陳述，建立自己的上下文，並且提供有關於是誰做出陳述的臨床認證。
雖然此規範的重點在於特定於病人的臨床聲明，但此resource也可適用於其他與健康照護相關的聲明，如研究方案設計、醫療發票和其他不必然與特定於病人或臨床相關的活動。
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))
If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
若重大傷病註記為「是」，則重大傷病代碼與病名必填
(Composition.section.where(code.coding.code.all($this = '11338-1')).entry.resolve().where(($this is Observation) and (code.coding.code.all($this = '11338-1')) and (value.ofType(boolean) = true)).exists()) implies (Composition.section.where(code.coding.code.all($this = '11338-1')).section.where(code.coding.code.all($this = '11338-1')).entry.resolve().where($this is Condition).exists())
Document[classCode="DOC" and moodCode="EVN" and isNormalAct()]
不重複的ID用以識別儲存在特定FHIR Server中的Composition紀錄，通常又稱為邏輯性ID。
一個resource使用新增操作(create operation)提交給伺服器時是此resource唯一沒有id的時刻
應填入於中醫門診單之病歷表單版本號Sheet Version
關於resource的metadata。這是由基礎建設維護的內容。對內容的改變可能並不總是與resource的版本改變相關。
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Additional content defined by implementations
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.
The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
When the resource last changed - e.g. when the version changed.
This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a [read](http://hl7.org/fhir/R4/http.html#read) interaction.
Identifies where the resource comes from
A uri that identifies the source system of the resource. This provides a minimal amount of [Provenance](http://hl7.org/fhir/R4/provenance.html#) information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.
In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
Profiles this resource claims to conform to
A list of profiles (references to [StructureDefinition](http://hl7.org/fhir/R4/structuredefinition.html#) resources) that this resource claims to conform to. The URL is a reference to [StructureDefinition.url](http://hl7.org/fhir/R4/structuredefinition-definitions.html#StructureDefinition.url).
It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.
Security Labels applied to this resource
Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.
Security Labels from the Healthcare Privacy and Security Classification System.
Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.
The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.
Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
構建resource時遵循的一系列規則的參照，在處理內容時必須理解這些規則。通常這是IG定義特殊規則及其他profiles的參照。
宣告這套規則限制了內容只能被有限的貿易夥伴所理解。這從本質上限制了資料的長期有用性。然而，現有的健康生態體系高度分裂，還沒有準備好以普遍可計算的方式定義、收集和交換資料。只要有可能，實作者和(或)規範編寫者應該避免使用這個資料項目。通常，在使用時，此URL是對實作指引的參照，此指引將這些特殊規則與其他profiles、value sets等一起定義為其敘述的一部分。
This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
提供語言是為了支援索引和可存取性(通常，文字表述轉語音等服務使用此語言標籤)。html lanuage tag適用於此敘述。resource上的語言標籤可用於指定從resource中的資料所產成的其他表述之語言。不是所有的內容都必須使用此基礎語言。不應該假定Resource.language自動適用於敘述。如果指定語言，它也應該被指定在html中的div元素(關於xml:lang和html lang屬性之間的關係，見HTML5中的規則)。
人類語言；鼓勵使用所綁定值集中的代碼，但不強制一定要使用此值集，你也可使用其他值集的代碼或單純以文字表示。
人可讀的敘述，包含resource的摘要，可用於向人表述resource的內容。敘述不需要對所有的結構化資料進行編碼，但需要包含足夠的細節使人在閱讀敘述時理解「臨床安全性」。resource定義可定義哪些內容應該在敘述中表示，以確保臨床安全。
內嵌(contained)的resource沒有敘述，非內嵌(contained)的resource則 **建議應該(SHOULD)** 有敘述。在某些情況下，resource可能只有文字表述，很少或沒有額外的離散資料(只要滿足所有minOccurs=1的資料項目)。這對於來自舊有系統的資料可能是必要的，在這些系統中，從 「文字表述區塊(text blob) 」獲取訊息，或者文字表述是額外的原始輸入或敘述，而編碼訊息是後來添加的。
可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理，對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充，但作為擴充定義的一部分，有一套要求 **必須（SHALL）** 滿足。
無論使用或定義擴充的機構或管轄區，任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。
此擴充的資料項目可能會完全修正或改變其他資料項目的意涵，需特別留意。
可以用來表示不屬於資料項目的基本定義的附加資訊，並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常，修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理，對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充，但作為擴充定義的一部分，有一套要求 **必須（SHALL）** 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。 修飾用的擴充資料項目 **必須沒有(SHALL NOT)** 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。
修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互操作性。更多訊息，請參見[修飾用的資料項目擴充之定義](http://hl7.org/fhir/R4/extensibility.html#modifierExtension)。
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
不分版本的臨床文件架構(Composition)識別碼。[應填入於中醫門診單之病歷表單編號]
與版本無關的Composition識別碼。隨著時間的推移，該識別碼將保持不變。
類似於 CDA 中的 ClinicalDocument/setId。請參閱resource定義中的討論，了解它們之間的關係。
usual | official | temp | secondary | old (If known)
Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.
Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.
This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Identifies the purpose for this identifier, if known .
A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.
This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.
Allows users to make use of identifiers when the identifier system is not known.
A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Establishes the namespace for the value - that is, a URL that describes a set values that are unique.
Identifier.system is always case sensitive.
There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.
The portion of the identifier typically relevant to the user and which is unique within the context of the system.
If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the [Rendered Value extension](http://hl7.org/fhir/R4/extension-rendered-value.html). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)
Time period when id is/was valid for use
Time period during which identifier is/was valid for use.
Role.effectiveTime or implied by context
Organization that issued id (may be just text)
Organization that issued/manages the identifier.
The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper
registered | partial | preliminary | final | amended | corrected +
此composition的工作流程/臨床狀態。狀態是指文件的臨床狀態的標識。
如果一個composition被標記為撤回(withdraw)，那麼該系列中的composition/文件或者此composition或文件系列中的資料，若未被明確標記為(該撤回)不可信的情況下，則不應向用戶展示。「錯誤輸入 (entered-in-error)標籤是此composition為何被標記為修飾用資料項目(modifier)的原因。 某些報告工作流程要求最終文件的原始敘述永不更改；意即只能添加新的敘述。composition resource 沒有明確的狀態(status)來明確註明是否適用此業務規則。如有需要，這將透過擴充來處理。
This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Composition的工作流程/臨床狀態；應填入所綁定值集中的其中一個代碼。
interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"
指定特定類型的composition（如病史和體檢、出院摘要、病程紀錄）。這通常等同於製作composition的目的。
Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
應填入所綁定值集中適合的代碼，確定無適合的代碼才可以使用其他值集的代碼來表示。
fhir:CodeableConcept rdfs:subClassOf dt:CD
composition類型的分類 - 有助於索引和查詢。這可能是由 Composition Type 中指定的代碼隱含或衍生出來的。
composition是關於誰或什麼的。composition可以是關於一個人（病人或醫護人員）、一個設備（如機器），甚至是一群對象（如關於一群牲畜的文件，或一群有共同曝露的病人）。
對於臨床文件來說，這通常是指病人。
Literal reference, Relative, internal or absolute URL
A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.
Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
Type the reference refers to (e.g. "Patient")
The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).
This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.
Aa resource (or, for logical models, the URI of the logical model).
Logical reference, when literal reference is not known
An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.
When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
Plain text narrative that identifies the resource in addition to the resource reference.
This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
描述與該文件相關的臨床就醫事件或照護類型。
unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
composition上的最後修改日期可能在文件被證明日期之後而未更改。這意味著修改過的文件上的日期是修改日期，而非原始撰寫之日期。
dateTime 用於追蹤、組織版本和查詢。請注意：這是創作此版本Composition的時間。打包成文檔時，Bundle.timestamp 是打包日期。
DocumentReference.content.attachment.date, DocumentReference.created
指明誰對composition中的資訊負責，而不一定是誰輸入了它。
對於許多composition來說，標題與文本或 Composition.type 的顯示名稱相同（如 「會診﹙consultation﹚」或 「病程紀錄﹙progress note﹚」）。請注意：CDA 並不強制要求標題，但目前還沒有發現省略標題有用的情況，因此在此強制要求標題。歡迎在試用區間對這一要求提出反饋意見。
DocumentReference.description, DocumentReference.content.attachment.title
此資料項目的確切使用，以及與高度敏感文件相關的執行和問題超出了基本規範的範圍，並委託給實作Profiles（見安全小節）。 此資料項目被標記為修飾用，因為高度機密的文件不能被當作非機密文件處理。
應填入所綁定值集中的其中一個代碼。
每位參與者只需每位證明者只列一次
Extensions that cannot be ignored even if unrecognized
May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
personal | professional | legal | official
認證者提供的認證類型；應填入所綁定值集中的其中一個代碼。
implied by .authenticator/.legalAuthenticator
指明composition中的資訊何時被認為是準確的。（自那時起可能發生了變化）。
./time[type="TS" and isNormalDatatype()]
./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
指明負責持續維護和存取composition/文件資訊的機構或團體
當此文件是衍生自composition時非常有用。它提供了如何獲取文件的最新版本的指導。這是可選項，因為有時編寫系統並不知道可以根據情境推斷。不過，在處理派生文件時，了解這一資訊非常重要，因此鼓勵提供一個保管者。
指明在哪裡可以找到當前版本、在哪裡可以報告問題等
.participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
要參照（使用 relatesTo）「document」type的 Bundle 或其他只有識別碼的 Composition，請使用帶有識別碼的 resourceReference。
如果此文件附加了另一個文件，那麼如果不存取參照的文件，就無法完全理解此文件。
檔案之間的關係型別；應填入所綁定值集中的其中一個代碼。
.target[classCode="DOC", moodCode="EVN"].id
記錄的臨床服務，例如：結腸鏡檢查或闌尾切除術。
事件需要與類型資料項目保持一致，但如果需求，也可以提供更多的詳細資訊。
此代碼表代表了正在被記錄的主要臨床行為
一個概念可能透過正式參照專門術語或本體論來定義，或者可以由文字提供。
一個事件可以進一步專門化 typeCode 中固有的行為，例如：當它僅僅是「處置報告」，而該處置是「結腸鏡檢查」。如果包含一個或多個事件，它們 **必須沒有(SHALL NOT)** 與 classCode、practiceSettingCode 或 typeCode 中固有的值相衝突，因為這樣的衝突會造成模糊不清的情況。這個簡短的代碼清單提供用作某些類型查詢的關鍵字。
可參考所綁定值集，但此值集只是針對這個欄位的一個可能值的範例，不預期也不鼓勵使用者一定要使用此值集的代碼。
此文件涵蓋的時間區間，這並不是聲明此文件是這一個時間區間的完整代表，而只是表明它記錄了這段時間內發生的事件。
在描述被記錄下來的事件，這些事件可以是以代碼的形式、參考資料的形式，或者兩者都有的形式來呈現。
它描述了正在被記錄的主要臨床活動，比如說進行一次結腸鏡檢查或是闌尾切除手術。在某些情況下，這些臨床事件本身就包含在其typeCode中，例如：在「病史與體檢報告」中，所記錄的過程就必然是進行「病史與體檢」的行為。這些臨床事件可以以代碼的形式被記錄，或者作為對其他resource的參照。
事件可以進一步細化類型編碼中的固有行為，例如，事件只是程序報告，而程序是結腸鏡檢查。如果包含一個或多個事件，它們不得與類別編碼、診療設置編碼或類型代碼中固有的值相衝 突，因為這樣的衝突會造成模稜兩可的情況。本編碼簡表可用作某些類型查詢的關鍵詞。
A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
exists(f:text) or exists(f:entry) or exists(f:section)
A section can only have an emptyReason if it is empty
not(exists(f:emptyReason) and exists(f:entry))
./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
此特定小節的標籤。這將是文件呈現內容的一部分，通常用於建立目錄。
標題為人類讀者指明小節。標題必須與作為 section.content 參照目標的resource的敘述一致。通常章節 **建議應該(SHOULD)** 有標題，但在某些文件中，這可能是不必要的或不適當的。通常情況下，當一個小節有其自己足夠區分的標題的子小節，或只有單一小節的文件時，就會這樣。大多數IG會要求小節標題是必填的資料項目。
不同類型的文件常常會有標準化的小節標題，這些標題為人們提供如何組織文件的指引。
一個用於指明小節中所含內容種類的代碼，這個代碼必須與小節的標題相一致。
提供給文件中主題的標籤是標準化的，並且可以被電腦程式識別和處理。
指明誰對小節中的資訊負責，而不一定是誰輸入了它。
當小節與composition描述的對象無關時，此小節是關於誰/什麼。
當小節的實際焦點不是composition描述的對象，而是代表與對象相關的某事物或某人時，例如：（對於病人對象）配偶、父母、胎兒或捐贈者。如果沒有指定焦點，則假定焦點為父小節的焦點，或者對於Composition本身中的小節，為Composition的對象。具有焦點的小節只 **必須（SHALL）** 包含對象（病人、對象、焦點等）與小節焦點相匹配的resources，或者是沒有對象的resources（少數resources）。
通常，文件中的小節是關於該文件的描述對象，無論是病人、一群病人、位置、設備或其他。對於某些種類的文件，有些小節實際上包含有關的實體資料。典型的例子包括新生兒出院病摘中關於母親的小節，或者家族病史文件中關於每個家庭成員的小節，當然還有很多其他例子。
.subject? (CDA did not differentiate between subject and focus)
將文件中特定小節的內容簡化成容易理解的文字形式，便於人類閱讀和解釋。
一個供人閱讀的敘述，包含小節的核實內容，用以展現resource的內容供人類閱讀。這段敘述不需要涵蓋所有結構化的資料，但必須包含足夠的細節，確保僅透過閱讀這段敘述的人能夠在臨床上獲得安全且準確的資訊。
文件Profile可能會定義應在敘述中呈現哪些內容，以確保臨床安全。
條目清單是如何準備的 - 它是一個適合持續維護的工作清單，還是代表從另一個來源截取的項目清單的快照，或者是一個準備好的清單，在該清單中，項目可能被標記為已添加、修改或刪除。
這個資料項目被標記為修飾用，是因為不應將變更清單(a change list)誤解為完整清單(a complete list)。
小節有多種使用方式，因此必須清楚地了解如何安全地使用其中的條目。
應用程式 **建議應該(SHOULD)** 按照給定的順序來顯示有序清單，但也可以允許用戶按照他們自己的偏好進行重新排序。如果沒有明確指定順序，則該順序是不確定的，雖然清單可能仍有某種排列順序。
這對於展示和呈現是重要的，清單可能會進行排序，以便將重要的資訊放在前面，或將相關的條目分組。
鼓勵使用所綁定值集中的代碼，但不強制一定要使用此值集，你也可使用其他值集的代碼或單純以文字表示。
提供一個連結用於參照或查看支持此小節內容的資料
指向那些提供小節中敘述內容的實際resource的參照
如果清單中沒有條目，則 **建議應該(SHOULD)** 提供 emptyReason。
.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
如果小節為空，則說明清單為空的原因。一個空的小節通常有一些文字說明空的原因。
當一個小節是空的，其空白的原因對於理解該小節非常重要。需要注意的是，這個代碼是用於當整個小節的內容都沒有被包括時，它並不適用於個別項目被省略的情形，若為個別項目被省略的情況，開發者可以考慮在該條目中添加文字說明或標記。
允許捕捉像是「不存在」或「未詢問」這樣的情況，這對於大多數清單來說可能很重要。
嵌套小節主要是為了幫助讀者快速找到文件中的特定內容
The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
A code identifying the kind of content contained within the section. This must be consistent with the section title.
The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Provides computable standardized labels to topics within the document.
Highest level of education [US Standard Certificate of Death]
Classification of a section of a composition/document.
Identifies who is responsible for the information in this section, not necessarily who typed it in.
Identifies who is responsible for the content.
Who/what the section is about, when it is not about the subject of composition
The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
Text summary of the section, for human interpretation
A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Document profiles may define what content should be represented in the narrative to ensure clinical safety.
How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
The processing mode that applies to this section.
Specifies the order applied to the items in the section entries.
Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
What order applies to the items in the entry.
.outboundRelationship[typeCode=COMP].sequenceNumber > 1
A reference to data that supports this section
A reference to the actual resource from which the narrative in the section is derived.
If there are no entries in the list, an emptyReason SHOULD be provided.
If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Allows capturing things like "none exist" or "not asked" which can be important for most lists.
A nested sub-section within this section.
Nested sections are primarily used to help human readers navigate to particular portions of the document.
Allergies and adverse reactions Document
History of Major illnesses and injuries Narrative
Multidisciplinary Comprehensive plan of care note
Relevant diagnostic tests/laboratory data note
Narrative diagnostic report [Interpretation]