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

• Content
• Detailed Descriptions
• Mappings
• Examples
• XML
• JSON
• TTL

Resource Profile: 文件參照(DocumentReference TWCM)

此文件參照(DocumentReference TWCM)Profile說明本IG如何進一步定義臺灣核心-文件參照(TW Core DocumentReference) Profile以呈現門診單之文件參照的詳細資料，可通用於中西醫各科別。

Usages:

• Use this Profile: 中醫-資料交換基本單位(Bundle TWCM)
• Refer to this Profile: 關懷計畫(CarePlan TWCM), 中醫-臨床文件架構(Composition TWCM), 文件參照(DocumentReference TWCM), 檢驗檢查(Observation TWCM)... Show 19 more, 血壓(ObservationBloodPressure TWCM), 血型(ObservationBloodtype TWCM), 身高(ObservationBodyHeight TWCM), 體溫(ObservationBodyTemp TWCM), 體重(ObservationBodyWeight TWCM), 教育程度(ObservationEducationLevel TWCM), 脈搏(ObservationHeartRate TWCM), 問診(ObservationInquiry TWCM), 望診(ObservationInspection TWCM), 聞診(ObservationListeningSmelling TWCM), 重大傷病註記(ObservationMajorIllness TWCM), 職業(ObservationOccupation TWCM), 切診(ObservationPalpation TWCM), 病人脈象(ObservationPulseCondition TWCM), 個人史(ObservationSocialHistory TWCM), 生命徵象(ObservationVitalSigns TWCM), 中醫-處置或手術(Procedure TWCM), 病人治則(ProcedureTherapeuticPrinciples TWCM) and 服務請求(ServiceRequest TWCM)
• Examples for this Profile: DocumentReference/DocumentReferenceTWCM-min
• CapabilityStatements using this Profile: 臺灣中醫實作指引-用戶端(TWCM Client) and 臺灣中醫實作指引-伺服端(TWCM Server)

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.

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	TWCoreDocumentReference	文件的參照
DocumentReference.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	創建此內容所依據的一組規則
DocumentReference.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
DocumentReference.masterIdentifier	S This element must be supported. Σ This element is included in summaries.	0..1	Identifier	主版本的識別碼
DocumentReference.status	?! This element is a modifier element. S This element must be supported. Σ This element is included in summaries.	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): 文件參照的狀態；應填入所綁定值集中的其中一個代碼。 Required Pattern: current
DocumentReference.type	S This element must be supported.	0..1	CodeableConceptTW	文件的類型（如果可能，使用 LOINC 代碼） Binding: LOINC Code Document Type值集 (extensible): 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。
DocumentReference.category	S This element must be supported.	0..*	CodeableConceptTW	文件的類別 Binding: LOINC Document Class值集 (extensible): 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。
DocumentReference.subject	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(病人資料(Patient TWCM))	文件描述的對象是誰/是什麼？
DocumentReference.date	S This element must be supported. Σ This element is included in summaries.	0..1	instant	文件參照的創建時間是何時？
DocumentReference.author	S This element must be supported. Σ This element is included in summaries.	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) | TW Core Implantable Device | 病人資料(Patient TWCM) | TW Core RelatedPerson)	誰以及/或什麼創建了文件
DocumentReference.authenticator		0..1	Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole | 醫事機構(Organization TWCM))	誰/什麼對文件進行了認證
DocumentReference.custodian		0..1	Reference(醫事機構(Organization TWCM))	維護此文件的機構
DocumentReference.content	S This element must be supported. Σ This element is included in summaries.	1..*	BackboneElement	被參照的文件。[應填入門診病摘之圖檔報告檔名或附件檔名(title)]
DocumentReference.content.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.content.attachment	S This element must be supported. Σ This element is included in summaries.	1..1	Attachment	存取文件的位置
DocumentReference.content.attachment.contentType	S This element must be supported. Σ This element is included in summaries.	1..1	code	【因FHIR必填】Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
DocumentReference.content.attachment.data	S This element must be supported.	1..1	base64Binary	資料之內容，必須轉成Base 64格式。
DocumentReference.content.attachment.title	Σ This element is included in summaries.	1..1	string	檔案名稱應包含副檔名。[應填入門診病摘之圖檔報告檔名Image File Name或附件檔名Reference Doc File Name] Example General: Official Corporate Logo
DocumentReference.context	S This element must be supported. Σ This element is included in summaries.	0..1	BackboneElement	文件的臨床背景
DocumentReference.context.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.context.encounter		0..*	Reference(就醫事件(Encounter TWCM))	文件內容的臨床背景
DocumentReference.context.sourcePatientInfo		0..1	Reference(病人資料(Patient TWCM))	來源的病人人口統計資料
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
DocumentReference.status	Base	required	DocumentReferenceStatus	📍4.0.1	FHIR Std.
DocumentReference.type	Base	extensible	LOINC Code Document Type值集	📦2.77	臺灣核心實作指引 v0.3
DocumentReference.category	Base	extensible	LOINC Document Class值集	📦2.77	臺灣核心實作指引 v0.3
DocumentReference.content.​attachment.contentType	Base	required	MimeType	📍4.0.1	FHIR Std.

Constraints

Id

Grade

Path(s)

Description

Expression

This structure is derived from TWCoreDocumentReference

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference			TWCoreDocumentReference
DocumentReference.status		1..1	code	current | superseded | entered-in-error Required Pattern: current
DocumentReference.subject		1..1	Reference(病人資料(Patient TWCM))	文件描述的對象是誰/是什麼？
DocumentReference.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) | TW Core Implantable Device | 病人資料(Patient TWCM) | TW Core RelatedPerson)	誰以及/或什麼創建了文件
DocumentReference.authenticator		0..1	Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole | 醫事機構(Organization TWCM))	誰/什麼對文件進行了認證
DocumentReference.custodian		0..1	Reference(醫事機構(Organization TWCM))	維護此文件的機構
DocumentReference.relatesTo
DocumentReference.relatesTo.target		1..1	Reference(文件參照(DocumentReference TWCM))	存在此關係的目標文件
DocumentReference.content		1..*	BackboneElement	被參照的文件。[應填入門診病摘之圖檔報告檔名或附件檔名(title)]
DocumentReference.content.attachment	S This element must be supported.	1..1	Attachment	存取文件的位置
DocumentReference.content.attachment.contentType	S This element must be supported.	1..1	code	【因FHIR必填】Mime type of the content, with charset etc.
DocumentReference.content.attachment.data	S This element must be supported.	1..1	base64Binary	資料之內容，必須轉成Base 64格式。
DocumentReference.content.attachment.title		1..1	string	檔案名稱應包含副檔名。[應填入門診病摘之圖檔報告檔名Image File Name或附件檔名Reference Doc File Name]
DocumentReference.context	S This element must be supported.	0..1	BackboneElement	文件的臨床背景
DocumentReference.context.encounter		0..*	Reference(就醫事件(Encounter TWCM))	文件內容的臨床背景
DocumentReference.context.sourcePatientInfo		0..1	Reference(病人資料(Patient TWCM))	來源的病人人口統計資料
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	TWCoreDocumentReference	文件的參照
DocumentReference.id	Σ This element is included in summaries.	0..1	id	不重複的ID用以識別儲存在特定FHIR Server中的DocumentReference紀錄，通常又稱為邏輯性ID。
DocumentReference.meta	Σ This element is included in summaries.	0..1	Meta	此DocumentReference Resource的metadata
DocumentReference.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	創建此內容所依據的一組規則
DocumentReference.language		0..1	code	用以表述DocumentReference Resource內容的語言。 Binding: CommonLanguages (preferred): 人類語言；鼓勵使用CommonLanguages代碼表中的代碼，但不強制一定要使用此代碼表，你也可使用其他代碼表的代碼或單純以文字表示。 Additional Bindings Purpose AllLanguages Max Binding Example Value: zh-TW
DocumentReference.text		0..1	Narrative	DocumentReference Resource之內容摘要以供人閱讀 This profile does not constrain the narrative in regard to content, language, or traceability to data elements
DocumentReference.contained		0..*	Resource	Contained, inline Resources
DocumentReference.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
DocumentReference.masterIdentifier	S This element must be supported. Σ This element is included in summaries.	0..1	Identifier	主版本的識別碼
DocumentReference.identifier	Σ This element is included in summaries.	0..*	Identifier	文件的其他的識別碼
DocumentReference.status	?! This element is a modifier element. S This element must be supported. Σ This element is included in summaries.	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): 文件參照的狀態；應填入所綁定值集中的其中一個代碼。 Required Pattern: current
DocumentReference.docStatus	Σ This element is included in summaries.	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): 基礎文件的狀態；應填入所綁定值集中的其中一個代碼。
DocumentReference.type	S This element must be supported.	0..1	CodeableConceptTW	文件的類型（如果可能，使用 LOINC 代碼） Binding: LOINC Code Document Type值集 (extensible): 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。
DocumentReference.category	S This element must be supported.	0..*	CodeableConceptTW	文件的類別 Binding: LOINC Document Class值集 (extensible): 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。
DocumentReference.subject	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(病人資料(Patient TWCM))	文件描述的對象是誰/是什麼？
DocumentReference.date	S This element must be supported. Σ This element is included in summaries.	0..1	instant	文件參照的創建時間是何時？
DocumentReference.author	S This element must be supported. Σ This element is included in summaries.	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) | TW Core Implantable Device | 病人資料(Patient TWCM) | TW Core RelatedPerson)	誰以及/或什麼創建了文件
DocumentReference.authenticator		0..1	Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole | 醫事機構(Organization TWCM))	誰/什麼對文件進行了認證
DocumentReference.custodian		0..1	Reference(醫事機構(Organization TWCM))	維護此文件的機構
DocumentReference.relatesTo	Σ This element is included in summaries.	0..*	BackboneElement	與其他文件的關係
DocumentReference.relatesTo.id		0..1	string	Unique id for inter-element referencing
DocumentReference.relatesTo.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.relatesTo.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.relatesTo.code	Σ This element is included in summaries.	1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): 文件之間的關係類型；應填入所綁定值集中的其中一個代碼。
DocumentReference.relatesTo.target	Σ This element is included in summaries.	1..1	Reference(文件參照(DocumentReference TWCM))	存在此關係的目標文件
DocumentReference.description	Σ This element is included in summaries.	0..1	string	人可讀的描述。
DocumentReference.securityLabel		0..*	CodeableConceptTW	文件的安全標籤(security-tags) Binding: All Security Labels (extensible): 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。
DocumentReference.content	S This element must be supported. Σ This element is included in summaries.	1..*	BackboneElement	被參照的文件。[應填入門診病摘之圖檔報告檔名或附件檔名(title)]
DocumentReference.content.id		0..1	string	Unique id for inter-element referencing
DocumentReference.content.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.content.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.content.attachment	S This element must be supported. Σ This element is included in summaries.	1..1	Attachment	存取文件的位置
DocumentReference.content.attachment.id		0..1	string	Unique id for inter-element referencing
DocumentReference.content.attachment.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
DocumentReference.content.attachment.contentType	S This element must be supported. Σ This element is included in summaries.	1..1	code	【因FHIR必填】Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
DocumentReference.content.attachment.language	Σ This element is included in summaries.	0..1	code	Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
DocumentReference.content.attachment.data	S This element must be supported.	1..1	base64Binary	資料之內容，必須轉成Base 64格式。
DocumentReference.content.attachment.url	Σ This element is included in summaries.	0..1	url	Uri where the data can be found Example General: http://www.acme.com/logo-small.png
DocumentReference.content.attachment.size	Σ This element is included in summaries.	0..1	unsignedInt	Number of bytes of content (if url provided)
DocumentReference.content.attachment.hash	Σ This element is included in summaries.	0..1	base64Binary	Hash of the data (sha-1, base64ed)
DocumentReference.content.attachment.title	Σ This element is included in summaries.	1..1	string	檔案名稱應包含副檔名。[應填入門診病摘之圖檔報告檔名Image File Name或附件檔名Reference Doc File Name] Example General: Official Corporate Logo
DocumentReference.content.attachment.creation	Σ This element is included in summaries.	0..1	dateTime	Date attachment was first created
DocumentReference.content.format	Σ This element is included in summaries.	0..1	Coding	文件的格式/內容規則。 Binding: DocumentReferenceFormatCodeSet (preferred): 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。
DocumentReference.context	S This element must be supported. Σ This element is included in summaries.	0..1	BackboneElement	文件的臨床背景
DocumentReference.context.id		0..1	string	Unique id for inter-element referencing
DocumentReference.context.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.context.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.context.encounter		0..*	Reference(就醫事件(Encounter TWCM))	文件內容的臨床背景
DocumentReference.context.event		0..*	CodeableConceptTW	正在記錄的主要臨床行為 Binding: v3 Code System ActCode (example): 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。
DocumentReference.context.period	Σ This element is included in summaries.	0..1	Period	被記錄的服務時間
DocumentReference.context.facilityType		0..1	CodeableConcept	病人接受治療的機構類型 Binding: FacilityTypeCodeValueSet (example): 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。
DocumentReference.context.practiceSetting		0..1	CodeableConceptTW	內容創建的額外細節(例如：臨床專業) Binding: PracticeSettingCodeValueSet (example): 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。
DocumentReference.context.sourcePatientInfo		0..1	Reference(病人資料(Patient TWCM))	來源的病人人口統計資料
DocumentReference.context.related		0..*	Reference(Resource)	相關的識別碼或resources
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
DocumentReference.language	Base	preferred	Common Languages	📦4.0.1	FHIR Std.
DocumentReference.status	Base	required	DocumentReferenceStatus	📍4.0.1	FHIR Std.
DocumentReference.docStatus	Base	required	CompositionStatus	📍4.0.1	FHIR Std.
DocumentReference.type	Base	extensible	LOINC Code Document Type值集	📦2.77	臺灣核心實作指引 v0.3
DocumentReference.category	Base	extensible	LOINC Document Class值集	📦2.77	臺灣核心實作指引 v0.3
DocumentReference.relatesTo.​code	Base	required	DocumentRelationshipType	📍4.0.1	FHIR Std.
DocumentReference.securityLabel	Base	extensible	SecurityLabels	📦4.0.1	FHIR Std.
DocumentReference.content.​attachment.contentType	Base	required	MimeType	📍4.0.1	FHIR Std.
DocumentReference.content.​attachment.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
DocumentReference.content.​format	Base	preferred	DocumentReference Format Code Set	📦4.0.1	FHIR Std.
DocumentReference.context.​event	Base	example	v3 Code System ActCode	📦3.0.0	THO v7.4
DocumentReference.context.​facilityType	Base	example	Facility Type Code Value Set	📦4.0.1	FHIR Std.
DocumentReference.context.​practiceSetting	Base	example	Practice Setting Code Value Set	📦4.0.1	FHIR Std.

Constraints

Id

Grade

Path(s)

Description

Expression

This structure is derived from TWCoreDocumentReference

Summary

Mandatory: 3 elements
Must-Support: 4 elements

Structures

This structure refers to these other structures:

• 病人資料(Patient TWCM) (https://www.nricm.edu.tw/twcm/StructureDefinition/patient-twcm)
• 健康照護服務提供人員資料(Practitioner TWCM) (https://www.nricm.edu.tw/twcm/StructureDefinition/practitioner-twcm)
• TW Core PractitionerRole (https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/PractitionerRole-twcore)
• 醫事機構(Organization TWCM) (https://www.nricm.edu.tw/twcm/StructureDefinition/organization-twcm)
• TW Core Implantable Device (https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Device-twcore)
• TW Core RelatedPerson (https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/RelatedPerson-twcore)
• 文件參照(DocumentReference TWCM) (https://www.nricm.edu.tw/twcm/StructureDefinition/documentreference-twcm)
• 就醫事件(Encounter TWCM) (https://www.nricm.edu.tw/twcm/StructureDefinition/encounter-twcm)

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	TWCoreDocumentReference	文件的參照
DocumentReference.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	創建此內容所依據的一組規則
DocumentReference.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
DocumentReference.masterIdentifier	S This element must be supported. Σ This element is included in summaries.	0..1	Identifier	主版本的識別碼
DocumentReference.status	?! This element is a modifier element. S This element must be supported. Σ This element is included in summaries.	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): 文件參照的狀態；應填入所綁定值集中的其中一個代碼。 Required Pattern: current
DocumentReference.type	S This element must be supported.	0..1	CodeableConceptTW	文件的類型（如果可能，使用 LOINC 代碼） Binding: LOINC Code Document Type值集 (extensible): 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。
DocumentReference.category	S This element must be supported.	0..*	CodeableConceptTW	文件的類別 Binding: LOINC Document Class值集 (extensible): 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。
DocumentReference.subject	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(病人資料(Patient TWCM))	文件描述的對象是誰/是什麼？
DocumentReference.date	S This element must be supported. Σ This element is included in summaries.	0..1	instant	文件參照的創建時間是何時？
DocumentReference.author	S This element must be supported. Σ This element is included in summaries.	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) | TW Core Implantable Device | 病人資料(Patient TWCM) | TW Core RelatedPerson)	誰以及/或什麼創建了文件
DocumentReference.authenticator		0..1	Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole | 醫事機構(Organization TWCM))	誰/什麼對文件進行了認證
DocumentReference.custodian		0..1	Reference(醫事機構(Organization TWCM))	維護此文件的機構
DocumentReference.content	S This element must be supported. Σ This element is included in summaries.	1..*	BackboneElement	被參照的文件。[應填入門診病摘之圖檔報告檔名或附件檔名(title)]
DocumentReference.content.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.content.attachment	S This element must be supported. Σ This element is included in summaries.	1..1	Attachment	存取文件的位置
DocumentReference.content.attachment.contentType	S This element must be supported. Σ This element is included in summaries.	1..1	code	【因FHIR必填】Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
DocumentReference.content.attachment.data	S This element must be supported.	1..1	base64Binary	資料之內容，必須轉成Base 64格式。
DocumentReference.content.attachment.title	Σ This element is included in summaries.	1..1	string	檔案名稱應包含副檔名。[應填入門診病摘之圖檔報告檔名Image File Name或附件檔名Reference Doc File Name] Example General: Official Corporate Logo
DocumentReference.context	S This element must be supported. Σ This element is included in summaries.	0..1	BackboneElement	文件的臨床背景
DocumentReference.context.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.context.encounter		0..*	Reference(就醫事件(Encounter TWCM))	文件內容的臨床背景
DocumentReference.context.sourcePatientInfo		0..1	Reference(病人資料(Patient TWCM))	來源的病人人口統計資料
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
DocumentReference.status	Base	required	DocumentReferenceStatus	📍4.0.1	FHIR Std.
DocumentReference.type	Base	extensible	LOINC Code Document Type值集	📦2.77	臺灣核心實作指引 v0.3
DocumentReference.category	Base	extensible	LOINC Document Class值集	📦2.77	臺灣核心實作指引 v0.3
DocumentReference.content.​attachment.contentType	Base	required	MimeType	📍4.0.1	FHIR Std.

Constraints

Id

Grade

Path(s)

Description

Expression

Differential View

This structure is derived from TWCoreDocumentReference

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference			TWCoreDocumentReference
DocumentReference.status		1..1	code	current | superseded | entered-in-error Required Pattern: current
DocumentReference.subject		1..1	Reference(病人資料(Patient TWCM))	文件描述的對象是誰/是什麼？
DocumentReference.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) | TW Core Implantable Device | 病人資料(Patient TWCM) | TW Core RelatedPerson)	誰以及/或什麼創建了文件
DocumentReference.authenticator		0..1	Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole | 醫事機構(Organization TWCM))	誰/什麼對文件進行了認證
DocumentReference.custodian		0..1	Reference(醫事機構(Organization TWCM))	維護此文件的機構
DocumentReference.relatesTo
DocumentReference.relatesTo.target		1..1	Reference(文件參照(DocumentReference TWCM))	存在此關係的目標文件
DocumentReference.content		1..*	BackboneElement	被參照的文件。[應填入門診病摘之圖檔報告檔名或附件檔名(title)]
DocumentReference.content.attachment	S This element must be supported.	1..1	Attachment	存取文件的位置
DocumentReference.content.attachment.contentType	S This element must be supported.	1..1	code	【因FHIR必填】Mime type of the content, with charset etc.
DocumentReference.content.attachment.data	S This element must be supported.	1..1	base64Binary	資料之內容，必須轉成Base 64格式。
DocumentReference.content.attachment.title		1..1	string	檔案名稱應包含副檔名。[應填入門診病摘之圖檔報告檔名Image File Name或附件檔名Reference Doc File Name]
DocumentReference.context	S This element must be supported.	0..1	BackboneElement	文件的臨床背景
DocumentReference.context.encounter		0..*	Reference(就醫事件(Encounter TWCM))	文件內容的臨床背景
DocumentReference.context.sourcePatientInfo		0..1	Reference(病人資料(Patient TWCM))	來源的病人人口統計資料
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	TWCoreDocumentReference	文件的參照
DocumentReference.id	Σ This element is included in summaries.	0..1	id	不重複的ID用以識別儲存在特定FHIR Server中的DocumentReference紀錄，通常又稱為邏輯性ID。
DocumentReference.meta	Σ This element is included in summaries.	0..1	Meta	此DocumentReference Resource的metadata
DocumentReference.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	創建此內容所依據的一組規則
DocumentReference.language		0..1	code	用以表述DocumentReference Resource內容的語言。 Binding: CommonLanguages (preferred): 人類語言；鼓勵使用CommonLanguages代碼表中的代碼，但不強制一定要使用此代碼表，你也可使用其他代碼表的代碼或單純以文字表示。 Additional Bindings Purpose AllLanguages Max Binding Example Value: zh-TW
DocumentReference.text		0..1	Narrative	DocumentReference Resource之內容摘要以供人閱讀 This profile does not constrain the narrative in regard to content, language, or traceability to data elements
DocumentReference.contained		0..*	Resource	Contained, inline Resources
DocumentReference.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
DocumentReference.masterIdentifier	S This element must be supported. Σ This element is included in summaries.	0..1	Identifier	主版本的識別碼
DocumentReference.identifier	Σ This element is included in summaries.	0..*	Identifier	文件的其他的識別碼
DocumentReference.status	?! This element is a modifier element. S This element must be supported. Σ This element is included in summaries.	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): 文件參照的狀態；應填入所綁定值集中的其中一個代碼。 Required Pattern: current
DocumentReference.docStatus	Σ This element is included in summaries.	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): 基礎文件的狀態；應填入所綁定值集中的其中一個代碼。
DocumentReference.type	S This element must be supported.	0..1	CodeableConceptTW	文件的類型（如果可能，使用 LOINC 代碼） Binding: LOINC Code Document Type值集 (extensible): 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。
DocumentReference.category	S This element must be supported.	0..*	CodeableConceptTW	文件的類別 Binding: LOINC Document Class值集 (extensible): 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。
DocumentReference.subject	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(病人資料(Patient TWCM))	文件描述的對象是誰/是什麼？
DocumentReference.date	S This element must be supported. Σ This element is included in summaries.	0..1	instant	文件參照的創建時間是何時？
DocumentReference.author	S This element must be supported. Σ This element is included in summaries.	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) | TW Core Implantable Device | 病人資料(Patient TWCM) | TW Core RelatedPerson)	誰以及/或什麼創建了文件
DocumentReference.authenticator		0..1	Reference(健康照護服務提供人員資料(Practitioner TWCM) | TW Core PractitionerRole | 醫事機構(Organization TWCM))	誰/什麼對文件進行了認證
DocumentReference.custodian		0..1	Reference(醫事機構(Organization TWCM))	維護此文件的機構
DocumentReference.relatesTo	Σ This element is included in summaries.	0..*	BackboneElement	與其他文件的關係
DocumentReference.relatesTo.id		0..1	string	Unique id for inter-element referencing
DocumentReference.relatesTo.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.relatesTo.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.relatesTo.code	Σ This element is included in summaries.	1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): 文件之間的關係類型；應填入所綁定值集中的其中一個代碼。
DocumentReference.relatesTo.target	Σ This element is included in summaries.	1..1	Reference(文件參照(DocumentReference TWCM))	存在此關係的目標文件
DocumentReference.description	Σ This element is included in summaries.	0..1	string	人可讀的描述。
DocumentReference.securityLabel		0..*	CodeableConceptTW	文件的安全標籤(security-tags) Binding: All Security Labels (extensible): 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。
DocumentReference.content	S This element must be supported. Σ This element is included in summaries.	1..*	BackboneElement	被參照的文件。[應填入門診病摘之圖檔報告檔名或附件檔名(title)]
DocumentReference.content.id		0..1	string	Unique id for inter-element referencing
DocumentReference.content.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.content.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.content.attachment	S This element must be supported. Σ This element is included in summaries.	1..1	Attachment	存取文件的位置
DocumentReference.content.attachment.id		0..1	string	Unique id for inter-element referencing
DocumentReference.content.attachment.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
DocumentReference.content.attachment.contentType	S This element must be supported. Σ This element is included in summaries.	1..1	code	【因FHIR必填】Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
DocumentReference.content.attachment.language	Σ This element is included in summaries.	0..1	code	Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
DocumentReference.content.attachment.data	S This element must be supported.	1..1	base64Binary	資料之內容，必須轉成Base 64格式。
DocumentReference.content.attachment.url	Σ This element is included in summaries.	0..1	url	Uri where the data can be found Example General: http://www.acme.com/logo-small.png
DocumentReference.content.attachment.size	Σ This element is included in summaries.	0..1	unsignedInt	Number of bytes of content (if url provided)
DocumentReference.content.attachment.hash	Σ This element is included in summaries.	0..1	base64Binary	Hash of the data (sha-1, base64ed)
DocumentReference.content.attachment.title	Σ This element is included in summaries.	1..1	string	檔案名稱應包含副檔名。[應填入門診病摘之圖檔報告檔名Image File Name或附件檔名Reference Doc File Name] Example General: Official Corporate Logo
DocumentReference.content.attachment.creation	Σ This element is included in summaries.	0..1	dateTime	Date attachment was first created
DocumentReference.content.format	Σ This element is included in summaries.	0..1	Coding	文件的格式/內容規則。 Binding: DocumentReferenceFormatCodeSet (preferred): 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。
DocumentReference.context	S This element must be supported. Σ This element is included in summaries.	0..1	BackboneElement	文件的臨床背景
DocumentReference.context.id		0..1	string	Unique id for inter-element referencing
DocumentReference.context.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.context.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.context.encounter		0..*	Reference(就醫事件(Encounter TWCM))	文件內容的臨床背景
DocumentReference.context.event		0..*	CodeableConceptTW	正在記錄的主要臨床行為 Binding: v3 Code System ActCode (example): 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。
DocumentReference.context.period	Σ This element is included in summaries.	0..1	Period	被記錄的服務時間
DocumentReference.context.facilityType		0..1	CodeableConcept	病人接受治療的機構類型 Binding: FacilityTypeCodeValueSet (example): 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。
DocumentReference.context.practiceSetting		0..1	CodeableConceptTW	內容創建的額外細節(例如：臨床專業) Binding: PracticeSettingCodeValueSet (example): 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。
DocumentReference.context.sourcePatientInfo		0..1	Reference(病人資料(Patient TWCM))	來源的病人人口統計資料
DocumentReference.context.related		0..*	Reference(Resource)	相關的識別碼或resources
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
DocumentReference.language	Base	preferred	Common Languages	📦4.0.1	FHIR Std.
DocumentReference.status	Base	required	DocumentReferenceStatus	📍4.0.1	FHIR Std.
DocumentReference.docStatus	Base	required	CompositionStatus	📍4.0.1	FHIR Std.
DocumentReference.type	Base	extensible	LOINC Code Document Type值集	📦2.77	臺灣核心實作指引 v0.3
DocumentReference.category	Base	extensible	LOINC Document Class值集	📦2.77	臺灣核心實作指引 v0.3
DocumentReference.relatesTo.​code	Base	required	DocumentRelationshipType	📍4.0.1	FHIR Std.
DocumentReference.securityLabel	Base	extensible	SecurityLabels	📦4.0.1	FHIR Std.
DocumentReference.content.​attachment.contentType	Base	required	MimeType	📍4.0.1	FHIR Std.
DocumentReference.content.​attachment.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
DocumentReference.content.​format	Base	preferred	DocumentReference Format Code Set	📦4.0.1	FHIR Std.
DocumentReference.context.​event	Base	example	v3 Code System ActCode	📦3.0.0	THO v7.4
DocumentReference.context.​facilityType	Base	example	Facility Type Code Value Set	📦4.0.1	FHIR Std.
DocumentReference.context.​practiceSetting	Base	example	Practice Setting Code Value Set	📦4.0.1	FHIR Std.

Constraints

Id

Grade

Path(s)

Description

Expression

This structure is derived from TWCoreDocumentReference

Summary

Mandatory: 3 elements
Must-Support: 4 elements

Structures

This structure refers to these other structures:

• 病人資料(Patient TWCM) (https://www.nricm.edu.tw/twcm/StructureDefinition/patient-twcm)
• 健康照護服務提供人員資料(Practitioner TWCM) (https://www.nricm.edu.tw/twcm/StructureDefinition/practitioner-twcm)
• TW Core PractitionerRole (https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/PractitionerRole-twcore)
• 醫事機構(Organization TWCM) (https://www.nricm.edu.tw/twcm/StructureDefinition/organization-twcm)
• TW Core Implantable Device (https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Device-twcore)
• TW Core RelatedPerson (https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/RelatedPerson-twcore)
• 文件參照(DocumentReference TWCM) (https://www.nricm.edu.tw/twcm/StructureDefinition/documentreference-twcm)
• 就醫事件(Encounter TWCM) (https://www.nricm.edu.tw/twcm/StructureDefinition/encounter-twcm)

Other representations of profile: CSV, Excel, Schematron