MI-TW 緊急醫療救護實作指引 (MI-TW EMS IG)
1.0.0 - CI Build
This page is part of the MI-TW 緊急醫療救護實作指引 (MI-TW EMS IG) (v1.0.0: Releases) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
Active as of 2024-08-23 |
Definitions for the EMS-Procedure-ALS resource profile.
Guidance on how to interpret the contents of this table can be found here
0. Procedure | |
2. Procedure.partOf | |
Type | Reference(TW Core Procedure, TW Core Observation Laboratory Result, MedicationAdministration, EMS_處置項目_Procedure, EMS_ALS 處置_Procedure) |
4. Procedure.code | |
Definition | 所進行的特定處置。如果不能對處置的確切種類進行編碼,則使用文字(例如:「腹腔鏡闌尾切除術」)。 NEMSIS 對應 : eProcedures.03 - Procedure TEMSIS 對應 : eProcedures.T01 - 處置 |
Short | 處置的識別碼。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。[氣管內管]或[手動電擊] |
6. Procedure.subject | |
Type | Reference(EMS_傷病患資料_Patient) |
8. Procedure.encounter | |
Type | Reference(EMS_派遣資料_Encounter) |
10. Procedure.recorder | |
Type | Reference(PractitionerRole, RelatedPerson, EMS_傷病患資料_Patient, EMS_救護人員簽名(姓名)_Practitioner) |
12. Procedure.asserter | |
Type | Reference(RelatedPerson, TW Core Practitioner, PractitionerRole, EMS_傷病患資料_Patient) |
14. Procedure.complicationDetail | |
Type | Reference(EMS_現場狀況_Condition, EMS_過去病史_Condition) |
16. Procedure.note | |
Short | 關於此處置的附加資訊。當Procedure.code用於"氣管內管"時,note為[號數]、[固定深度 (cm)] ; 當用於"手動電擊"時,note為[次數]、[焦耳數] |
Must Support | true |
Guidance on how to interpret the contents of this table can be found here
0. Procedure | |
Definition | 正在或曾經對病人執行的動作。這可以是像手術這樣的身體介入,也可以是像長照服務、諮詢或催眠療法這樣的非侵入性介入。HL7 FHIR官網另有提到的例子包括例如包括診斷處置、內視鏡處置、活體組織切片、諮詢、物理治療、個人支持服務、日照服務、非緊急運輸、改善家居設施、健身活動等。處置可以由醫護人員、服務提供人員、朋友或親屬或在某些情況下由病人自己執行。 An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy. |
Short | 正在或曾經對病人執行的動作An action that is being or was performed on a patient |
Control | 0..* |
Is Modifier | false |
Summary | false |
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()) dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()) dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (text.`div`.exists()) |
2. Procedure.implicitRules | |
Definition | 構建resource時遵循的一系列規則的參照,在處理內容時必須理解這些規則。通常這是IG定義特殊規則及其他profiles的參照。 A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. |
Short | 創建此內容所依據的一組規則A set of rules under which this content was created |
Comments | 宣告這套規則限制了內容只能被有限的貿易夥伴所理解。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。 Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. |
Control | 0..1 |
Type | uri |
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
4. Procedure.text | |
Definition | 人可讀的敘述,包含resource的摘要,可用於向人表述resource的內容。敘述不需要對所有的結構化資料進行編碼,但需要包含足夠的細節使人在閱讀敘述時理解「臨床安全性」。resource定義可定義哪些內容應該在敘述中表示,以確保臨床安全。 A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. |
Short | Procedure Resource之內容摘要以供人閱讀Text summary of the resource, for human interpretation |
Comments | 內嵌(contained)的resource沒有敘述,非內嵌(contained)的resource則 建議應該(SHOULD) 有敘述。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。 Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. |
Control | 0..1 |
Type | Narrative |
Is Modifier | false |
Must Support | true |
Summary | false |
Alternate Names | narrative, html, xhtml, display |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
6. Procedure.modifierExtension | |
Definition | 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)。 May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | 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。Extensions that cannot be ignored |
Comments | 無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(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。 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. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them |
Summary | false |
Requirements | 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通性。更多訊息,請參見修飾用的資料項目擴充之定義。 Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
8. Procedure.partOf | |
Definition | 這個特定的處置是一個更大的事件中的一個組成部分或步驟 A larger event of which this particular procedure is a component or step. |
Short | 參照事件的一部分Part of referenced event |
Comments | MedicationAdministration.partOf有一個Procedure參照,但這不是一個迴圈參照。例如:麻醉的給藥(MedicationAdministration)是手術處置的一部分(MedicationAdministration.partOf = Procedure)。例如:為靜脈給藥插入靜脈口的處置是給藥的一部分(Procedure.partOf = MedicationAdministration)。 The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration). |
Control | 0..* |
Type | Reference(TW Core Procedure, TW Core Observation Laboratory Result, MedicationAdministration, EMS_處置項目_Procedure, EMS_ALS 處置_Procedure, Procedure, Observation) |
Is Modifier | false |
Summary | true |
Alternate Names | container |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
10. Procedure.status | |
Definition | 一個指定處置當前狀態的代碼。一般來說,它是進行中或完成的狀態。 A code specifying the state of the procedure. Generally, this will be the in-progress or completed state. |
Short | preparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknownpreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown |
Comments | 「未知」代碼不能用來表達其他狀態。當其中一個狀態適用時但編輯系統不知道此處置的當前狀態,應該使用「未知」代碼。 此資料項目被標記為修飾用,因為狀態包含標記resource當前無效的代碼。 The "unknown" code is not to be used to convey other statuses. The "unknown" code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. |
Control | 1..1 |
Binding | The codes SHALL be taken from EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1 (required to http://hl7.org/fhir/ValueSet/event-status|4.0.1 )應填入EventStatus值集中的其中一個代碼 A code specifying the state of the procedure. |
Type | code |
Is Modifier | true because 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 |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
12. Procedure.code | |
Definition | 所進行的特定處置。如果不能對處置的確切種類進行編碼,則使用文字(例如:「腹腔鏡闌尾切除術」)。 NEMSIS 對應 : eProcedures.03 - Procedure TEMSIS 對應 : eProcedures.T01 - 處置 The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy"). |
Short | 處置的識別碼。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。[氣管內管]或[手動電擊]Identification of the procedure |
Comments | 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. |
Control | 10..1 This element is affected by the following invariants: ele-1 |
Binding | For example codes, see ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code (example to http://hl7.org/fhir/ValueSet/procedure-code )可參考Procedure Codes(SNOMED CT)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。 A code to identify a specific procedure . |
Type | CodeableConcept(TW CodeableConcept) |
Is Modifier | false |
Must Support | true |
Requirements | 0..1主要僅用於解釋敘述性的resource。 0..1 to account for primarily narrative only resources. |
Alternate Names | type |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
14. Procedure.code.coding | |
Definition | 由專門術語系統(terminology system)所定義之代碼的參照。 A reference to a code defined by a terminology system. |
Short | 由專門術語系統(terminology system)定義的代碼Code defined by a terminology system |
Comments | 代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。 Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. |
Control | 0..* This element is affected by the following invariants: ele-1 |
Type | Coding(TW Coding) |
Is Modifier | false |
Must Support | true |
Requirements | 允許使用者在不知道識別碼系統的情況下利用識別碼 Allows for alternative encodings within a code system, and translations to other code systems. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Slicing | This element introduces a set of slices on Procedure.code.coding . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
16. Procedure.code.coding:icd10-pcs-2021 | |
Slice Name | icd10-pcs-2021 |
Definition | 由專門術語系統(terminology system)所定義之代碼的參照。 A reference to a code defined by a terminology system. |
Short | 此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。Code defined by a terminology system |
Comments | 代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。 Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. |
Control | 0..1* This element is affected by the following invariants: ele-1 |
Binding | The codes SHALL be taken from For codes, see 臺灣2021年中文版ICD-10-PCS值集 (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw )病情、問題或診斷的識別;應填入臺灣2021年中文版ICD-10-PCS值集值集中的其中一個代碼。 |
Type | Coding(TW Coding) |
Is Modifier | false |
Must Support | true |
Requirements | 允許使用者在不知道識別碼系統的情況下利用識別碼 Allows for alternative encodings within a code system, and translations to other code systems. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
18. Procedure.code.coding:icd10-pcs-2014 | |
Slice Name | icd10-pcs-2014 |
Definition | 由專門術語系統(terminology system)所定義之代碼的參照。 A reference to a code defined by a terminology system. |
Short | 此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。Code defined by a terminology system |
Comments | 代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。 Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. |
Control | 0..1* This element is affected by the following invariants: ele-1 |
Binding | The codes SHALL be taken from For codes, see 臺灣2014年中文版ICD-10-PCS值集 (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2014-tw )病情、問題或診斷的識別;應填入臺灣2014年中文版ICD-10-PCS值集值集中的其中一個代碼。 |
Type | Coding(TW Coding) |
Is Modifier | false |
Must Support | true |
Requirements | 允許使用者在不知道識別碼系統的情況下利用識別碼 Allows for alternative encodings within a code system, and translations to other code systems. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
20. Procedure.code.coding:icd9-cm-2001 | |
Slice Name | icd9-cm-2001 |
Definition | 由專門術語系統(terminology system)所定義之代碼的參照 A reference to a code defined by a terminology system. |
Short | 由專門術語系統(terminology system)定義的代碼Code defined by a terminology system |
Comments | 代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,例如:SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。 Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. |
Control | 0..1* This element is affected by the following invariants: ele-1 |
Binding | The codes SHALL be taken from For codes, see 臺灣2001年中文版ICD-9-CM值集 (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw ) |
Type | Coding(TW Coding) |
Is Modifier | false |
Must Support | true |
Requirements | 允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。 Allows for alternative encodings within a code system, and translations to other code systems. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
22. Procedure.code.coding:medical-service-payment | |
Slice Name | medical-service-payment |
Definition | 由專門術語系統(terminology system)所定義之代碼的參照。 A reference to a code defined by a terminology system. |
Short | 此為中央健康保險署(NHI)維護之醫療服務給付項目,主要針對申報使用,可免費使用,可依情境選用此代碼。Code defined by a terminology system |
Comments | 代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。 Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. |
Control | 0..1* This element is affected by the following invariants: ele-1 |
Binding | The codes SHALL be taken from For codes, see 臺灣藥品使用頻率值集 (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/medication-frequency-tw )病情、問題或診斷的識別;應填入臺灣2014年中文版ICD-10-PCS值集值集中的其中一個代碼。 |
Type | Coding(TW Coding) |
Is Modifier | false |
Must Support | true |
Requirements | 允許使用者在不知道識別碼系統的情況下利用識別碼 Allows for alternative encodings within a code system, and translations to other code systems. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
24. Procedure.code.coding:sct-procedures-ips | |
Slice Name | sct-procedures-ips |
Definition | 由專門術語系統(terminology system)所定義之代碼的參照。 A reference to a code defined by a terminology system. |
Short | 此為SNOMED CT處置代碼,若機構已有購買相關授權,亦可使用。Code defined by a terminology system |
Comments | 代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。 Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. |
Control | 0..1* This element is affected by the following invariants: ele-1 |
Binding | The codes SHALL be taken from For codes, see Procedures (SNOMED CT) - IPS (required to http://hl7.org/fhir/uv/ips/ValueSet/procedures-uv-ips )病情、問題或診斷的識別;應填入Procedures - IPS值集中的其中一個代碼。 |
Type | Coding(TW Coding) |
Is Modifier | false |
Must Support | true |
Requirements | 允許使用者在不知道識別碼系統的情況下利用識別碼 Allows for alternative encodings within a code system, and translations to other code systems. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
26. Procedure.code.text | |
Definition | 輸入資料的使用者所見/所選/所說的人類可讀文字表述,和(或)其代表使用者的預期含義。 A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. |
Short | 概念的文字表示法Plain text representation of the concept |
Comments | 很多時候,此文字表述與其中一個代碼的顯示名稱相同。 Very often the text is the same as a displayName of one of the codings. |
Control | 0..1 |
Type | string |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Requirements | 專門術語中的代碼並不總是能捕捉人類使用的細微差別的正確意義,或者根本就沒有合適的代碼;這些情況下,文字表述被用來捕捉來源的全部意義。 The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
28. Procedure.subject | |
Definition | 進行處置的病人、動物或實體集合(例如:特定的一群人)。 The person, animal or group on which the procedure was performed. |
Short | 處置服務的對象Who the procedure was performed on |
Control | 1..1 |
Type | Reference(EMS_傷病患資料_Patient, Patient, Group) |
Is Modifier | false |
Must Support | true |
Summary | true |
Alternate Names | patient |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
30. Procedure.encounter | |
Definition | 此「處置(Procedure)」記載在哪次的「就醫(Encounter)」紀錄或者與此處置紀錄密切相關的「就醫(Encounter)」紀錄 The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated. |
Short | 就醫(Encounter)紀錄作為處置的一部分Encounter created as part of |
Comments | 通常是此處置發生的就醫事件(Encounter),雖然有些活動可能在就醫結束之前或之後開始,但仍與就醫事件的情境有關。這筆紀錄表明與此處置紀錄相關的就醫事件。 This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. |
Control | 0..1 |
Type | Reference(EMS_派遣資料_Encounter, Encounter) |
Is Modifier | false |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
32. Procedure.performed[x] | |
Definition | 進行處置的估計或實際日期、日期時間、時間區間或年齡。允許一個時間區間來支持跨越一個日期以上的複雜處置,也允許捕捉處置的執行時間長度。 Estimated or actual date, date-time, period, or age when the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured. |
Short | 此處置何時執行的?When the procedure was performed |
Comments | 年齡一般用於病人報告其進行手術的年齡,像是20到25歲時。 dateTime支援一定的精度範圍,因為有些處置被報告為過去的處置,可能沒有毫秒的精度,而其他在就醫期間執行和記錄的處置可能有更精確的UTC時間戳記和時區。 Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone. |
Control | 0..1 |
Type | Choice of: dateTime, Period, string, Age, Range |
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Must Support Types | dateTime |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
34. Procedure.recorder | |
Definition | 記錄處置內容並對其內容負責的個人 Individual who recorded the record and takes responsibility for its content. |
Short | 誰記錄此處置Who recorded the procedure |
Control | 0..1 |
Type | Reference(PractitionerRole, RelatedPerson, EMS_傷病患資料_Patient, EMS_救護人員簽名(姓名)_Practitioner, Patient, Practitioner) |
Is Modifier | false |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
36. Procedure.asserter | |
Definition | 提出此處置說明的人 Individual who is making the procedure statement. |
Short | 聲稱有此處置的人Person who asserts this procedure |
Control | 0..1 |
Type | Reference(RelatedPerson, TW Core Practitioner, PractitionerRole, EMS_傷病患資料_Patient, Patient, Practitioner) |
Is Modifier | false |
Must Support | true |
Must Support Types | No must-support rules about the choice of types/profiles |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
38. Procedure.performer | |
Definition | 限於「真正的」人而不是設備 Limited to "real" people rather than equipment. |
Short | 執行處置的人員The people who performed the procedure |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
40. Procedure.performer.modifierExtension | |
Definition | 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)。 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). |
Short | 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。Extensions that cannot be ignored even if unrecognized |
Comments | 無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(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。 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. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | 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通性。更多訊息,請參見修飾用的資料項目擴充之定義。 Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
42. Procedure.performer.actor | |
Definition | 參與處置的健康照護服務提供人員 The practitioner who was involved in the procedure. |
Short | 參照至健康照護服務提供人員The reference to the practitioner |
Control | 1..1 |
Type | Reference(TW Core Practitioner, PractitionerRole, TW Core Organization Hospital Department, TW Core Patient, RelatedPerson, Device, Practitioner, Organization, Patient) |
Is Modifier | false |
Must Support | true |
Must Support Types | No must-support rules about the choice of types/profiles |
Summary | true |
Requirements | 一個參照至裝置(Device)的使用案例,例如:心律調整器。 A reference to Device supports use cases, such as pacemakers. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
44. Procedure.performer.onBehalfOf | |
Definition | 此裝置或健康照護服務提供人員所代表的機構 The organization the device or practitioner was acting on behalf of. |
Short | 此裝置(Device)或健康照護服務提供人員所屬機構(Organization)Organization the device or practitioner was acting for |
Control | 0..1 |
Type | Reference(TW Core Organization Hospital Department, Organization) |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | 健康照護服務提供人員和裝置可以與多個機構相關聯,此資料項目表明他們在執行行動時代表哪個機構。 Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
46. Procedure.bodySite | |
Definition | 詳細和結構化的解剖學位置資訊。允許多個位置—例如:一個病灶的多個活體組織切片。 Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion. |
Short | 目標身體部位。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。Target body sites |
Comments | 如果案例需要BodySite resource的屬性(例如:識別和各別追蹤),那麼就使用標準擴充[procedure-targetbodystructure](擴充-procedure-targetbodystructure.html)。 If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension procedure-targetbodystructure. |
Control | 0..* This element is affected by the following invariants: ele-1 |
Binding | For example codes, see SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site (example to http://hl7.org/fhir/ValueSet/body-site )可參考SNOMED CT Body Structures值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。 Codes describing anatomical locations. May include laterality. |
Type | CodeableConcept(TW CodeableConcept) |
Is Modifier | false |
Must Support | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
48. Procedure.complicationDetail | |
Definition | 在處置過程中或在執行結束後立即發生的任何併發症 Any complications that occurred during the procedure, or in the immediate post-performance period. |
Short | 處置後發生的病情、問題或診斷A condition that is a result of the procedure |
Control | 0..* |
Type | Reference(EMS_現場狀況_Condition, EMS_過去病史_Condition, Condition) |
Is Modifier | false |
Summary | false |
Requirements | 這是用來記錄作為處置結果的病情、問題或診斷,而不是作為處置原因的病情、問題或診斷。 This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
50. Procedure.note | |
Definition | 關於此處置的任何其他註釋和意見 Any other notes and comments about the procedure. |
Short | 關於此處置的附加資訊。當Procedure.code用於"氣管內管"時,note為[號數]、[固定深度 (cm)] ; 當用於"手動電擊"時,note為[次數]、[焦耳數]Additional information about the procedure |
Control | 0..* |
Type | Annotation |
Is Modifier | false |
Must Support | true |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Guidance on how to interpret the contents of this table can be found here
0. Procedure | |||||
Definition | 正在或曾經對病人執行的動作。這可以是像手術這樣的身體介入,也可以是像長照服務、諮詢或催眠療法這樣的非侵入性介入。HL7 FHIR官網另有提到的例子包括例如包括診斷處置、內視鏡處置、活體組織切片、諮詢、物理治療、個人支持服務、日照服務、非緊急運輸、改善家居設施、健身活動等。處置可以由醫護人員、服務提供人員、朋友或親屬或在某些情況下由病人自己執行。 | ||||
Short | 正在或曾經對病人執行的動作 | ||||
Control | 0..* | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty() )dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource ( contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() )dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated ( contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() )dom-5: If a resource is contained in another resource, it SHALL NOT have a security label ( contained.meta.security.empty() )dom-6: A resource should have narrative for robust management ( text.`div`.exists() ) | ||||
2. Procedure.id | |||||
Definition | resource的邏輯ID,在resource的URL中使用。一旦指定,這個值永遠不會改變。 | ||||
Short | 不重複的ID用以識別儲存在特定FHIR Server中的Procedure紀錄,通常又稱為邏輯性ID。 | ||||
Comments | 一個resource使用新增操作(create operation)提交給伺服器時是此resource唯一沒有id的時刻 | ||||
Control | 0..1 | ||||
Type | id | ||||
Is Modifier | false | ||||
Summary | true | ||||
4. Procedure.meta | |||||
Definition | 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。 | ||||
Short | 此Procedure Resource的metadata | ||||
Control | 0..1 | ||||
Type | Meta | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
6. Procedure.implicitRules | |||||
Definition | 構建resource時遵循的一系列規則的參照,在處理內容時必須理解這些規則。通常這是IG定義特殊規則及其他profiles的參照。 | ||||
Short | 創建此內容所依據的一組規則 | ||||
Comments | 宣告這套規則限制了內容只能被有限的貿易夥伴所理解。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。 | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
8. Procedure.language | |||||
Definition | 編寫此resource的基礎語言 | ||||
Short | 用以表述Procedure Resource內容的語言 | ||||
Comments | 提供語言是為了支援索引和可存取性(通常,文字表述轉語音等服務使用此語言標籤)。html lanuage tag適用於此敘述。resource上的語言標籤可用於指定從resource中的資料所產成的其他表述之語言。不是所有的內容都必須使用此基礎語言。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)。 | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from CommonLanguages (preferred to http://hl7.org/fhir/ValueSet/languages )人類語言;鼓勵使用CommonLanguages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。
| ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Example | <br/><b>Value</b>:zh-TW | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
10. Procedure.text | |||||
Definition | 人可讀的敘述,包含resource的摘要,可用於向人表述resource的內容。敘述不需要對所有的結構化資料進行編碼,但需要包含足夠的細節使人在閱讀敘述時理解「臨床安全性」。resource定義可定義哪些內容應該在敘述中表示,以確保臨床安全。 | ||||
Short | Procedure Resource之內容摘要以供人閱讀 | ||||
Comments | 內嵌(contained)的resource沒有敘述,非內嵌(contained)的resource則 建議應該(SHOULD) 有敘述。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。 | ||||
Control | 0..1 | ||||
Type | Narrative | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Alternate Names | narrative, html, xhtml, display | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
12. Procedure.contained | |||||
Definition | 這些resource內嵌(contains)的resource不會另外存於任何FHIR伺服器,意即它們無法在任何FHIR伺服器中被找到,也無法有自己獨立的資料異動/交易(transaction)範圍。 | ||||
Short | 內嵌的(contained)、行內的Resources | ||||
Comments | 當內容可以從任何FHIR伺服器找到時,不應該以內嵌(contained)resource的方式呈現,因為一旦識別丟失,要再次恢復它是非常困難的(並且取決於情境)。內嵌(contained)的resource可在它們的meta資料項目中表述profiles和tag(標籤),但 必須沒有(SHALL NOT) 資訊安全標號(security labels)。 | ||||
Control | 0..* | ||||
Type | Resource | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | inline resources, anonymous resources, contained resources | ||||
14. Procedure.extension | |||||
Definition | 可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。 | ||||
Short | 擴充的資料項目 | ||||
Comments | 無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(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。 | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
16. Procedure.modifierExtension | |||||
Definition | 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)。 | ||||
Short | 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。 | ||||
Comments | 無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(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。 | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them | ||||
Summary | false | ||||
Requirements | 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通性。更多訊息,請參見修飾用的資料項目擴充之定義。 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
18. Procedure.identifier | |||||
Definition | 由執行者或其他系統指定給此處置的業務用識別碼,即使此resource作更新及在伺服器之間的傳遞,此識別碼仍保持不變。 | ||||
Short | 此處置的外部識別碼 | ||||
Comments | 這是一個業務識別碼,不是一個resource識別碼(詳見討論)。最好的做法是該識別碼只出現在單個resource實例上,但是業務實務有可能會規定可以在多個resource實例中具有相同識別碼—甚至可能具有不同的resource型例。例如:多個 「Patient(病人)」和 「Person(個人)」resource實例可能共用同一個社會保險號碼。 | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 0..* | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | 允許識別各參與系統所知的此處置資訊,並在各伺服器之間保持一致的方式。 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
20. Procedure.instantiatesCanonical | |||||
Definition | 指向此處置全部或部分遵守的FHIR定義的計畫書(protocol)、指南(guideline)、醫令集(orderset)或其他定義的URL。 | ||||
Short | 實例化FHIR計畫書(protocol)或定義 | ||||
Control | 0..* | ||||
Type | canonical(PlanDefinition, ActivityDefinition, Measure, OperationDefinition, Questionnaire) | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
22. Procedure.instantiatesUri | |||||
Definition | 指向此處置全部或部分的外部維護之計畫書(protocol)、指南(guideline)、醫令集(orderset)或其他定義的URL。 | ||||
Short | 實例化外部計畫書(protocol)或定義 | ||||
Comments | 這可能是一個HTML頁面、PDF等,也可能只是一個不可分解的URI識別碼。 | ||||
Control | 0..* | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
24. Procedure.basedOn | |||||
Definition | 對一個resource的參照,此resource包含此處置請求的細節。 | ||||
Short | 此Procedure是基於什麼而履行? | ||||
Control | 0..* | ||||
Type | Reference(CarePlan, ServiceRequest) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Alternate Names | fulfills | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
26. Procedure.partOf | |||||
Definition | 這個特定的處置是一個更大的事件中的一個組成部分或步驟 | ||||
Short | 參照事件的一部分 | ||||
Comments | MedicationAdministration.partOf有一個Procedure參照,但這不是一個迴圈參照。例如:麻醉的給藥(MedicationAdministration)是手術處置的一部分(MedicationAdministration.partOf = Procedure)。例如:為靜脈給藥插入靜脈口的處置是給藥的一部分(Procedure.partOf = MedicationAdministration)。 | ||||
Control | 0..* | ||||
Type | Reference(TW Core Procedure, TW Core Observation Laboratory Result, MedicationAdministration, EMS_處置項目_Procedure, EMS_ALS 處置_Procedure) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Alternate Names | container | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
28. Procedure.status | |||||
Definition | 一個指定處置當前狀態的代碼。一般來說,它是進行中或完成的狀態。 | ||||
Short | preparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknown | ||||
Comments | 「未知」代碼不能用來表達其他狀態。當其中一個狀態適用時但編輯系統不知道此處置的當前狀態,應該使用「未知」代碼。 此資料項目被標記為修飾用,因為狀態包含標記resource當前無效的代碼。 | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from EventStatus (required to http://hl7.org/fhir/ValueSet/event-status|4.0.1 )應填入EventStatus值集中的其中一個代碼 | ||||
Type | code | ||||
Is Modifier | true because 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 | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
30. Procedure.statusReason | |||||
Definition | 捕捉Procedure當前狀態的原因 | ||||
Short | 當前狀態的原因。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。 | ||||
Comments | 這通常只用於「例外」狀態像是「未完成」、「暫停」或「終止」。執行此處置的原因是在reasonCode中說明,而不是在這裡。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | For example codes, see ProcedureNotPerformedReason(SNOMED-CT) (example to http://hl7.org/fhir/ValueSet/procedure-not-performed-reason )可參考Procedure Not Performed Reason(SNOMED-CT)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。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Alternate Names | Suspended Reason, Cancelled Reason | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
32. Procedure.category | |||||
Definition | 對處置進行分類的代碼(例如:「手術處置」)。主要為了搜尋、排序和顯示時使用。 | ||||
Short | 處置的分類。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。 | ||||
Comments | 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. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | For example codes, see ProcedureCategoryCodes(SNOMEDCT) (example to http://hl7.org/fhir/ValueSet/procedure-category )可參考Procedure Category Codes(SNOMED CT)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。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
34. Procedure.code | |||||
Definition | 所進行的特定處置。如果不能對處置的確切種類進行編碼,則使用文字(例如:「腹腔鏡闌尾切除術」)。 NEMSIS 對應 : eProcedures.03 - Procedure TEMSIS 對應 : eProcedures.T01 - 處置 | ||||
Short | 處置的識別碼。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。[氣管內管]或[手動電擊] | ||||
Comments | 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. | ||||
Control | 1..1 This element is affected by the following invariants: ele-1 | ||||
Binding | For example codes, see ProcedureCodes(SNOMEDCT) (example to http://hl7.org/fhir/ValueSet/procedure-code )可參考Procedure Codes(SNOMED CT)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。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Requirements | 0..1主要僅用於解釋敘述性的resource。 | ||||
Alternate Names | type | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
36. Procedure.code.id | |||||
Definition | resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。 | ||||
Short | 唯一可識別ID,以供資料項目間相互參照。 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
38. Procedure.code.extension | |||||
Definition | 擴充的資料項目 | ||||
Short | 擴充的資料項目 | ||||
Comments | 無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(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。 | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on Procedure.code.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
40. Procedure.code.coding | |||||
Definition | 由專門術語系統(terminology system)所定義之代碼的參照。 | ||||
Short | 由專門術語系統(terminology system)定義的代碼 | ||||
Comments | 代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。 | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Requirements | 允許使用者在不知道識別碼系統的情況下利用識別碼 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
Slicing | This element introduces a set of slices on Procedure.code.coding . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
42. Procedure.code.coding:icd10-pcs-2021 | |||||
Slice Name | icd10-pcs-2021 | ||||
Definition | 由專門術語系統(terminology system)所定義之代碼的參照。 | ||||
Short | 此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 | ||||
Comments | 代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from 臺灣2021年中文版ICD-10-PCS值集 (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw )病情、問題或診斷的識別;應填入臺灣2021年中文版ICD-10-PCS值集值集中的其中一個代碼。 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Requirements | 允許使用者在不知道識別碼系統的情況下利用識別碼 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
44. Procedure.code.coding:icd10-pcs-2014 | |||||
Slice Name | icd10-pcs-2014 | ||||
Definition | 由專門術語系統(terminology system)所定義之代碼的參照。 | ||||
Short | 此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 | ||||
Comments | 代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from 臺灣2014年中文版ICD-10-PCS值集 (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2014-tw )病情、問題或診斷的識別;應填入臺灣2014年中文版ICD-10-PCS值集值集中的其中一個代碼。 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Requirements | 允許使用者在不知道識別碼系統的情況下利用識別碼 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
46. Procedure.code.coding:icd9-cm-2001 | |||||
Slice Name | icd9-cm-2001 | ||||
Definition | 由專門術語系統(terminology system)所定義之代碼的參照 | ||||
Short | 由專門術語系統(terminology system)定義的代碼 | ||||
Comments | 代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,例如:SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from 臺灣2001年中文版ICD-9-CM值集 (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw ) | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Requirements | 允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
48. Procedure.code.coding:medical-service-payment | |||||
Slice Name | medical-service-payment | ||||
Definition | 由專門術語系統(terminology system)所定義之代碼的參照。 | ||||
Short | 此為中央健康保險署(NHI)維護之醫療服務給付項目,主要針對申報使用,可免費使用,可依情境選用此代碼。 | ||||
Comments | 代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from 臺灣藥品使用頻率值集 (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/medication-frequency-tw )病情、問題或診斷的識別;應填入臺灣2014年中文版ICD-10-PCS值集值集中的其中一個代碼。 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Requirements | 允許使用者在不知道識別碼系統的情況下利用識別碼 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
50. Procedure.code.coding:sct-procedures-ips | |||||
Slice Name | sct-procedures-ips | ||||
Definition | 由專門術語系統(terminology system)所定義之代碼的參照。 | ||||
Short | 此為SNOMED CT處置代碼,若機構已有購買相關授權,亦可使用。 | ||||
Comments | 代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from Procedures (SNOMED CT) - IPS (required to http://hl7.org/fhir/uv/ips/ValueSet/procedures-uv-ips )病情、問題或診斷的識別;應填入Procedures - IPS值集中的其中一個代碼。 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Requirements | 允許使用者在不知道識別碼系統的情況下利用識別碼 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
52. Procedure.code.text | |||||
Definition | 輸入資料的使用者所見/所選/所說的人類可讀文字表述,和(或)其代表使用者的預期含義。 | ||||
Short | 概念的文字表示法 | ||||
Comments | 很多時候,此文字表述與其中一個代碼的顯示名稱相同。 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | 專門術語中的代碼並不總是能捕捉人類使用的細微差別的正確意義,或者根本就沒有合適的代碼;這些情況下,文字表述被用來捕捉來源的全部意義。 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
54. Procedure.subject | |||||
Definition | 進行處置的病人、動物或實體集合(例如:特定的一群人)。 | ||||
Short | 處置服務的對象 | ||||
Control | 1..1 | ||||
Type | Reference(EMS_傷病患資料_Patient) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Alternate Names | patient | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
56. Procedure.encounter | |||||
Definition | 此「處置(Procedure)」記載在哪次的「就醫(Encounter)」紀錄或者與此處置紀錄密切相關的「就醫(Encounter)」紀錄 | ||||
Short | 就醫(Encounter)紀錄作為處置的一部分 | ||||
Comments | 通常是此處置發生的就醫事件(Encounter),雖然有些活動可能在就醫結束之前或之後開始,但仍與就醫事件的情境有關。這筆紀錄表明與此處置紀錄相關的就醫事件。 | ||||
Control | 0..1 | ||||
Type | Reference(EMS_派遣資料_Encounter) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
58. Procedure.performed[x] | |||||
Definition | 進行處置的估計或實際日期、日期時間、時間區間或年齡。允許一個時間區間來支持跨越一個日期以上的複雜處置,也允許捕捉處置的執行時間長度。 | ||||
Short | 此處置何時執行的? | ||||
Comments | 年齡一般用於病人報告其進行手術的年齡,像是20到25歲時。 dateTime支援一定的精度範圍,因為有些處置被報告為過去的處置,可能沒有毫秒的精度,而其他在就醫期間執行和記錄的處置可能有更精確的UTC時間戳記和時區。 | ||||
Control | 0..1 | ||||
Type | Choice of: dateTime, Period, string, Age, Range | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Must Support Types | dateTime | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
60. Procedure.recorder | |||||
Definition | 記錄處置內容並對其內容負責的個人 | ||||
Short | 誰記錄此處置 | ||||
Control | 0..1 | ||||
Type | Reference(PractitionerRole, RelatedPerson, EMS_傷病患資料_Patient, EMS_救護人員簽名(姓名)_Practitioner) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
62. Procedure.asserter | |||||
Definition | 提出此處置說明的人 | ||||
Short | 聲稱有此處置的人 | ||||
Control | 0..1 | ||||
Type | Reference(RelatedPerson, TW Core Practitioner, PractitionerRole, EMS_傷病患資料_Patient) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Must Support Types | No must-support rules about the choice of types/profiles | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
64. Procedure.performer | |||||
Definition | 限於「真正的」人而不是設備 | ||||
Short | 執行處置的人員 | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
66. Procedure.performer.id | |||||
Definition | resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。 | ||||
Short | 唯一可識別ID,以供資料項目間相互參照。 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
68. Procedure.performer.extension | |||||
Definition | 可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。 | ||||
Short | 擴充的資料項目 | ||||
Comments | 無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(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。 | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
70. Procedure.performer.modifierExtension | |||||
Definition | 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)。 | ||||
Short | 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。 | ||||
Comments | 無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(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。 | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | 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通性。更多訊息,請參見修飾用的資料項目擴充之定義。 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
72. Procedure.performer.function | |||||
Definition | 區分執行者在處置中的參與型別,例如:外科醫生、麻醉師、內視鏡醫生。 | ||||
Short | 執行的型別 | ||||
Comments | 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. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | For example codes, see ProcedurePerformerRoleCodes (example to http://hl7.org/fhir/ValueSet/performer-role )可參考Procedure Performer Role Codes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。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Requirements | 允許針對不同執行者的參與型別進行澄清以消除歧義 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
74. Procedure.performer.actor | |||||
Definition | 參與處置的健康照護服務提供人員 | ||||
Short | 參照至健康照護服務提供人員 | ||||
Control | 1..1 | ||||
Type | Reference(TW Core Practitioner, PractitionerRole, TW Core Organization Hospital Department, TW Core Patient, RelatedPerson, Device) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Must Support Types | No must-support rules about the choice of types/profiles | ||||
Summary | true | ||||
Requirements | 一個參照至裝置(Device)的使用案例,例如:心律調整器。 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
76. Procedure.performer.onBehalfOf | |||||
Definition | 此裝置或健康照護服務提供人員所代表的機構 | ||||
Short | 此裝置(Device)或健康照護服務提供人員所屬機構(Organization) | ||||
Control | 0..1 | ||||
Type | Reference(TW Core Organization Hospital Department) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | 健康照護服務提供人員和裝置可以與多個機構相關聯,此資料項目表明他們在執行行動時代表哪個機構。 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
78. Procedure.location | |||||
Definition | 實際發生處置的地點(Location)。例如:新生兒在家裡出生、在餐廳做氣管切開術。 | ||||
Short | 處置發生的地點(Location)? | ||||
Control | 0..1 | ||||
Type | Reference(Location) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | 將一個處置與可能保存紀錄的地點(Location)聯繫起來 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
80. Procedure.reasonCode | |||||
Definition | 進行此處置的原因代碼。這可能是某種型別的編碼,也可能只是文字表述。 | ||||
Short | 處置執行原因代碼 | ||||
Comments | 當一個代碼足以描述原因時,使用Procedure.reasonCode。當參照一個resource時,使用Procedure.reasonReference以傳達更多的資訊,如發病日期。Procedure.reasonCode和Procedure.reasonReference不應該是重複的。對於一個單一的原因,Procedure.reasonCode或Procedure.reasonReference都可以被使用。Procedure.reasonCode可以是一個摘要代碼,或者Procedure.reasonReference可以用Condition | Observation | Procedure | DiagnosticReport | DocumentReference來參照一個非常精確的原因定義。如果Procedure.reasonCode和Procedure.reasonReference描述的是處置的不同原因,則兩者都可以使用。 | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | For example codes, see ProcedureReasonCodes (example to http://hl7.org/fhir/ValueSet/procedure-reason )可[參考Procedure Reason Codes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。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
82. Procedure.reasonReference | |||||
Definition | 為什麼進行此處置的原因 | ||||
Short | 執行此處置的原因 | ||||
Comments | 一個處置有可能成為另一個處置(如C-Section)的理由(如硬膜外)。其他的例子包括擴張的內窺鏡檢查和活檢(診斷和治療的結合)。 當一個代碼充分地描述了原因時,使用Procedure.reasonCode。當引用一個resource時,使用Procedure.reasonReference,這樣可以傳達更多的資訊,如發病日期。Procedure.reasonCode和Procedure.reasonReference不應該是重複的。對於一個單一的原因,Procedure.reasonCode或Procedure.reasonReference都可以被使用。Procedure.reasonCode可以是一個摘要代碼,或者Procedure.reasonReference可以用Condition | Observation | Procedure | DiagnosticReport | DocumentReference來引用一個非常精確的原因定義。如果Procedure.reasonCode和Procedure.reasonReference描述的是處置的不同原因,則兩者都可以使用。 | ||||
Control | 0..* | ||||
Type | Reference(TW Core Condition, TW Core Observation Laboratory Result, TW Core Procedure, DiagnosticReport, DocumentReference) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
84. Procedure.bodySite | |||||
Definition | 詳細和結構化的解剖學位置資訊。允許多個位置—例如:一個病灶的多個活體組織切片。 | ||||
Short | 目標身體部位。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。 | ||||
Comments | 如果案例需要BodySite resource的屬性(例如:識別和各別追蹤),那麼就使用標準擴充[procedure-targetbodystructure](擴充-procedure-targetbodystructure.html)。 | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | For example codes, see SNOMEDCTBodyStructures (example to http://hl7.org/fhir/ValueSet/body-site )可參考SNOMED CT Body Structures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。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
86. Procedure.outcome | |||||
Definition | 處置的結果—它是否解決了當初執行處置所要解決的問題? | ||||
Short | 處置的結果。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。 | ||||
Comments | 如果結果只包含敘述性文字,可用CodeableConcept.text來說明。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | For example codes, see ProcedureOutcomeCodes(SNOMEDCT) (example to http://hl7.org/fhir/ValueSet/procedure-outcome )可參考Procedure Outcome Codes(SNOMED CT)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。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
88. Procedure.report | |||||
Definition | 這可能是組織學結果、病理學報告、手術報告等。 | ||||
Short | 此處置產生的任何報告 | ||||
Comments | 有可能會有多份報告—例如:如果這是一個需要進行多次活體組織切片的處置,會產生一些解剖病理報告。 | ||||
Control | 0..* | ||||
Type | Reference(DiagnosticReport, DocumentReference, Composition) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
90. Procedure.complication | |||||
Definition | 在處置過程中,或在處置後不久發生的任何併發症。這些通常與紀錄分開追蹤,紀錄通常描述處置本身,而不是任何 「處置後」的問題。 | ||||
Short | 處置後的併發症 | ||||
Comments | 如果併發症僅由敘述性文字表達,可用CodeableConcept.text來說明。 | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | For example codes, see Condition/Problem/DiagnosisCodes (example to http://hl7.org/fhir/ValueSet/condition-code )可參考Condition/Problem/Diagnosis Codes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。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
92. Procedure.complicationDetail | |||||
Definition | 在處置過程中或在執行結束後立即發生的任何併發症 | ||||
Short | 處置後發生的病情、問題或診斷 | ||||
Control | 0..* | ||||
Type | Reference(EMS_現場狀況_Condition, EMS_過去病史_Condition) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | 這是用來記錄作為處置結果的病情、問題或診斷,而不是作為處置原因的病情、問題或診斷。 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
94. Procedure.followUp | |||||
Definition | 如果該處置需要特定的後續行動—例如拆除縫線。 後續行動可以表現為一個簡單的說明,也可能是更複雜的,在這種情況下,可以使用CarePlan resource。 | ||||
Short | 追蹤說明。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。 | ||||
Comments | 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. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | For example codes, see ProcedureFollowUpCodes(SNOMEDCT) (example to http://hl7.org/fhir/ValueSet/procedure-followup )可參考Procedure Follow up Codes(SNOMED CT)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。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
96. Procedure.note | |||||
Definition | 關於此處置的任何其他註釋和意見 | ||||
Short | 關於此處置的附加資訊。當Procedure.code用於"氣管內管"時,note為[號數]、[固定深度 (cm)] ; 當用於"手動電擊"時,note為[次數]、[焦耳數] | ||||
Control | 0..* | ||||
Type | Annotation | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
98. Procedure.focalDevice | |||||
Definition | 植入、移除或以其他方式操作的裝置(校準、更換電池、安裝義肢、安裝傷口真空裝置等),是處置的重點部分。 | ||||
Short | 處理、植入的或移除的裝置 | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
100. Procedure.focalDevice.id | |||||
Definition | resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。 | ||||
Short | 唯一可識別ID,以供資料項目間相互參照。 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
102. Procedure.focalDevice.extension | |||||
Definition | 可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。 | ||||
Short | 擴充的資料項目 | ||||
Comments | 無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(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。 | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
104. Procedure.focalDevice.modifierExtension | |||||
Definition | 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)。 | ||||
Short | 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。 | ||||
Comments | 無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(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。 | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | 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通性。更多訊息,請參見修飾用的資料項目擴充之定義。 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
106. Procedure.focalDevice.action | |||||
Definition | 處置過程中,設備改變的類型。 | ||||
Short | 改變裝置的種類 | ||||
Comments | 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. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHOULD be taken from ProcedureDeviceActionCodes (preferred to http://hl7.org/fhir/ValueSet/device-action )鼓勵使用Procedure Device Action Codes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。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
108. Procedure.focalDevice.manipulated | |||||
Definition | 在處置中被處理(改變)的裝置 | ||||
Short | 被改變的裝置 | ||||
Control | 1..1 | ||||
Type | Reference(Device) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
110. Procedure.usedReference | |||||
Definition | 指明藥品、裝置和作為處置一部分的任何其他物質 | ||||
Short | 處置中使用的項目/物品 | ||||
Comments | 對於實際植入或取出的裝置,使用Procedure.device。 | ||||
Control | 0..* | ||||
Type | Reference(Device, Medication, Substance) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | 用於追蹤污染等 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
112. Procedure.usedCode | |||||
Definition | 指明作為處置的一部分而使用的編碼項目 | ||||
Short | 處置中使用的項目之代碼 | ||||
Comments | 對於實際植入或取出的裝置,使用Procedure.device。 | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | For example codes, see FHIRDeviceTypes (example to http://hl7.org/fhir/ValueSet/device-kind )可參考FHIR Device Types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。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) |