電子病歷交換單張實作指引(EMR-IG)
0.1.0 - ci-build

This page is part of the 電子病歷交換單張實作指引(EMR-IG) (v0.1.0: Releases) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: ImageComposition - Detailed Descriptions

Draft as of 2024-01-31

Definitions for the ImageComposition resource profile.

Guidance on how to interpret the contents of this table can be found here

0. Composition
Short醫療影像及報告Composition
2. Composition.type
4. Composition.type.coding
Control1..1
Pattern Value{
  "system" : "http://loinc.org",
  "code" : "18782-3",
  "display" : "Radiology Study observation (narrative)"
}
6. Composition.subject
Control1..?
TypeReference(醫療影像及報告-病患基本資料)
8. Composition.encounter
TypeReference(醫療影像及報告-醫囑時間)
10. Composition.date
ShortComposition編輯時間
12. Composition.author
Short什麼機構撰寫此醫療影像及報告
Control0..1
TypeReference(醫療影像及報告-醫事機構基本資料)
14. Composition.title
Short醫療影像及報告
16. Composition.attester
Control0..1
18. Composition.attester.time
ShortComposition何時被證明
Must Supporttrue
20. Composition.attester.party
Short誰證明這個Composition
Control1..?
TypeReference(醫療影像及報告-醫事機構基本資料)
Must Supporttrue
22. Composition.section
ShortSection的標籤(例如:目錄)
24. Composition.section.code
Control1..?
Pattern Value{
  "coding" : [{
    "system" : "http://loinc.org",
    "code" : "30954-2",
    "display" : "Relevant diagnostic tests/laboratory data Narrative"
  }]
}
26. Composition.section.code.coding
Control1..?
28. Composition.section.text
ShortSection的摘要,供人解讀。
30. Composition.section.entry
Control5..?
SlicingThis element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • profile @ resolve()
  • 32. Composition.section.entry:Practitioner
    Slice NamePractitioner
    Short支援這個section的資料之參照
    Control1..1
    TypeReference(醫療影像及報告-醫事人員基本資料)
    34. Composition.section.entry:Condition
    Slice NameCondition
    Short支援這個section的資料之參照
    Control1..1
    TypeReference(醫療影像及報告-病史)
    36. Composition.section.entry:Observation
    Slice NameObservation
    Short支援這個section的資料之參照
    Control1..1
    TypeReference(醫療影像及報告-影像檢驗報告)
    38. Composition.section.entry:DiagnosticReport
    Slice NameDiagnosticReport
    Short支援這個section的資料之參照
    Control1..1
    TypeReference(DiagnosticReport Image)
    40. Composition.section.entry:ImagingStudy
    Slice NameImagingStudy
    Short支援這個section的資料之參照
    Control1..1
    TypeReference(醫療影像及報告-醫學影像內容)

    Guidance on how to interpret the contents of this table can be found here

    0. Composition
    Definition

    一組與健康照護相關的資訊,這些訊息被組合成一個單一的邏輯套件,提供一個單一的連貫的意義陳述,建立自己的上下文,並且提供有關於是誰做出陳述的臨床認證。


    A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.).

    Short醫療影像及報告CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
    Comments

    雖然此規範的重點在於特定於病人的臨床聲明,但此resource也可適用於其他與健康照護相關的聲明,如研究方案設計、醫療發票和其他不必然與特定於病人或臨床相關的活動。


    While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.

    Control0..*
    Is Modifierfalse
    Summaryfalse
    Invariantsdom-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. Composition.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.

    Control0..1
    Typeuri
    Is Modifiertrue 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 ValueThis primitive element may be present, or absent, or replaced by an extension
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    4. Composition.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污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。


    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.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
    Summaryfalse
    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操作性。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 Namesextensions, user content
    Invariantsele-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())
    6. Composition.identifier
    Definition

    與版本無關的Composition識別碼。隨著時間的推移,該識別碼將保持不變。


    A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time.

    Short不分版本的臨床文件架構(Composition)識別碼。Version-independent identifier for the Composition
    Comments

    類似於 CDA 中的 ClinicalDocument/setId。請參閱resource定義中的討論,了解它們之間的關係。


    Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.

    NoteThis is a business identifier, not a resource identifier (see discussion)
    Control0..1
    TypeIdentifier
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    8. Composition.status
    Definition

    此composition的工作流程/臨床狀態。狀態是指文件的臨床狀態的標識。


    The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document.

    Shortregistered | partial | preliminary | final | amended | corrected +preliminary | final | amended | entered-in-error
    Comments

    如果一個composition被標記為撤回(withdraw),那麼該系列中的composition/文件或者此composition或文件系列中的資料,若未被明確標記為(該撤回)不可信的情況下,則不應向用戶展示。「錯誤輸入 (entered-in-error)標籤是此composition為何被標記為修飾用資料項目(modifier)的原因。 某些報告工作流程要求最終文件的原始敘述永不更改;意即只能添加新的敘述。composition resource 沒有明確的狀態(status)來明確註明是否適用此業務規則。如有需要,這將透過擴充來處理。


    If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements.

    Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required.

    Control1..1
    BindingThe codes SHALL be taken from CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1
    (required to http://hl7.org/fhir/ValueSet/composition-status|4.0.1)

    Composition的工作流程/臨床狀態;應填入所綁定值集中的其中一個代碼。


    The workflow/clinical status of the composition.

    Typecode
    Is Modifiertrue 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 ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Requirements

    需要能夠標記為臨時(interim)、修改(amended)或撤回(withdrawn)的composition或文件。


    Need to be able to mark interim, amended, or withdrawn compositions or documents.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    10. Composition.type
    Definition

    指定特定類型的composition(如病史和體檢、出院摘要、病程紀錄)。這通常等同於製作composition的目的。


    Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition.

    ShortComposition的種類(如果可能請使用LOINC)Kind of composition (LOINC if possible)
    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.


    For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding.

    Control1..1
    This element is affected by the following invariants: ele-1
    BindingUnless not suitable, these codes SHALL be taken from The codes SHOULD be taken from FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodes
    (extensible to http://hl7.org/fhir/ValueSet/doc-typecodes)

    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。


    Type of a composition.

    TypeCodeableConcept(TW CodeableConcept)
    Is Modifierfalse
    Must Supporttrue
    Requirements

    描述composition的關鍵metadata資料項目,用於查詢/篩選。


    Key metadata element describing the composition, used in searching/filtering.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    12. Composition.type.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,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.

    Control10..1*
    This element is affected by the following invariants: ele-1
    TypeCoding(TW Coding)
    Is Modifierfalse
    Must Supporttrue
    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.

    Pattern Value{
      "system" : "http://loinc.org",
      "code" : "18782-3",
      "display" : "Radiology Study observation (narrative)"
    }
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    14. Composition.type.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.

    Control0..1
    Typestring
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    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.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    16. Composition.subject
    Definition

    composition是關於誰或什麼的。composition可以是關於一個人(病人或醫護人員)、一個設備(如機器),甚至是一群對象(如關於一群牲畜的文件,或一群有共同曝露的病人)。


    Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure).

    ShortComposition是關於誰和/或什麼Who and/or what the composition is about
    Comments

    對於臨床文件來說,這通常是指病人。


    For clinical documents, this is usually the patient.

    Control10..1
    TypeReference(醫療影像及報告-病患基本資料, Resource)
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Requirements

    查詢composition的基本metadata,指明compoisition/文件的作者和/或內容。


    Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    18. Composition.encounter
    Definition

    描述與該文件相關的臨床就醫事件或照護類型。


    Describes the clinical encounter or type of care this documentation is associated with.

    ShortComposition的情境Context of the Composition
    Control0..1
    TypeReference(醫療影像及報告-醫囑時間, Encounter)
    Is Modifierfalse
    Summarytrue
    Requirements

    為composition提供情境並支持查詢。


    Provides context for the composition and supports searching.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    20. Composition.date
    Definition

    composition編輯時間,即作者最後一次邏輯上更改composition的時間。


    The composition editing time, when the composition was last logically changed by the author.

    ShortComposition編輯時間Composition editing time
    Comments

    composition上的最後修改日期可能在文件被證明日期之後而未更改。這意味著修改過的文件上的日期是修改日期,而非原始撰寫之日期。


    The Last Modified Date on the composition may be after the date of the document was attested without being changed.

    Control1..1
    TypedateTime
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Requirements

    dateTime 用於追蹤、組織版本和查詢。請注意:這是創作此版本Composition的時間。打包成文檔時,Bundle.timestamp 是打包日期。


    dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    22. Composition.author
    Definition

    指明誰對composition中的資訊負責,而不一定是誰輸入了它。


    Identifies who is responsible for the information in the composition, not necessarily who typed it in.

    Short什麼機構撰寫此醫療影像及報告Who and/or what authored the composition
    Control1..1*
    TypeReference(醫療影像及報告-醫事機構基本資料, Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization)
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Requirements

    指明誰對內容負責


    Identifies who is responsible for the content.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    24. Composition.title
    Definition

    composition的正式可讀標籤


    Official human-readable label for the composition.

    Short醫療影像及報告Human Readable name/title
    Comments

    對於許多composition來說,標題與文本或 Composition.type 的顯示名稱相同(如 「會診﹙consultation﹚」或 「病程紀錄﹙progress note﹚」)。請注意:CDA 並不強制要求標題,但目前還沒有發現省略標題有用的情況,因此在此強制要求標題。歡迎在試用區間對這一要求提出反饋意見。


    For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.

    Control1..1
    Typestring
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    26. Composition.attester
    Definition

    證明composition/文件準確無誤的參與者


    A participant who has attested to the accuracy of the composition/document.

    Short證明Composition的準確性Attests to accuracy of composition
    Comments

    每位參與者只需每位證明者只列一次


    Only list each attester once.

    Control0..1*
    TypeBackboneElement
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Requirements

    指明對composition內容準確性的責任


    Identifies responsibility for the accuracy of the composition content.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    28. Composition.attester.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.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    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 Namesextensions, user content, modifiers
    Invariantsele-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())
    30. Composition.attester.mode
    Definition

    認證者提供的認證類型


    The type of attestation the authenticator offers.

    Shortpersonal | professional | legal | official
    Control1..1
    BindingThe codes SHALL be taken from CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
    (required to http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1)

    認證者提供的認證類型;應填入所綁定值集中的其中一個代碼。


    The way in which a person authenticated a composition.

    Typecode
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    指明認證的權威程度


    Indicates the level of authority of the attestation.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    32. Composition.attester.time
    Definition

    當composition被該方證實的時間


    When the composition was attested by the party.

    ShortComposition何時被證明When the composition was attested
    Control0..1
    TypedateTime
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summaryfalse
    Requirements

    指明composition中的資訊何時被認為是準確的。(自那時起可能發生了變化)。


    Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    34. Composition.attester.party
    Definition

    誰以指定的方式證明了此composition


    Who attested the composition in the specified way.

    Short誰證明這個CompositionWho attested the composition
    Control10..1
    TypeReference(醫療影像及報告-醫事機構基本資料, Patient, RelatedPerson, Practitioner, PractitionerRole, Organization)
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Requirements

    指明由誰承擔composition內容準確性的責任


    Identifies who has taken on the responsibility for accuracy of the composition content.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    36. Composition.custodian
    Definition

    指明負責持續維護和存取composition/文件資訊的機構或團體


    Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information.

    Short維護Composition的機構Organization which maintains the composition
    Comments

    當此文件是衍生自composition時非常有用。它提供了如何獲取文件的最新版本的指導。這是可選項,因為有時編寫系統並不知道可以根據情境推斷。不過,在處理派生文件時,了解這一資訊非常重要,因此鼓勵提供一個保管者。


    This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged.

    Control0..1
    TypeReference(TW Core Organization, Organization)
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Requirements

    指明在哪裡可以找到當前版本、在哪裡可以報告問題等


    Identifies where to go to find the current version, where to report issues, etc.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    38. Composition.section
    Definition

    構成composition的各小節


    The root of the sections that make up the composition.

    ShortSection的標籤(例如:目錄)Composition is broken into sections
    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
    cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
    ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
    cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
    40. Composition.section.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.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    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 Namesextensions, user content, modifiers
    Invariantsele-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. Composition.section.code
    Definition

    一個用於指明小節中所含內容種類的代碼,這個代碼必須與小節的標題相一致。


    A code identifying the kind of content contained within the section. This must be consistent with the section title.

    Short小節分類(建議)Classification of section (recommended)
    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.


    The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

    If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

    Control10..1
    This element is affected by the following invariants: ele-1
    BindingUnless not suitable, these codes SHALL be taken from For example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes
    (extensible to http://hl7.org/fhir/ValueSet/doc-section-codes)

    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。


    Classification of a section of a composition/document.

    TypeCodeableConcept(TW CodeableConcept)
    Is Modifierfalse
    Must Supporttrue
    Requirements

    提供給文件中主題的標籤是標準化的,並且可以被電腦程式識別和處理。


    Provides computable standardized labels to topics within the document.

    Pattern Value{
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "30954-2",
        "display" : "Relevant diagnostic tests/laboratory data Narrative"
      }]
    }
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    44. Composition.section.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,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.

    Control10..*
    This element is affected by the following invariants: ele-1
    TypeCoding(TW Coding)
    Is Modifierfalse
    Must Supporttrue
    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.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    46. Composition.section.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.

    Control0..1
    Typestring
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    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.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    48. Composition.section.text
    Definition

    一個供人閱讀的敘述,包含小節的核實內容,用以展現resource的內容供人類閱讀。這段敘述不需要涵蓋所有結構化的資料,但必須包含足夠的細節,確保僅透過閱讀這段敘述的人能夠在臨床上獲得安全且準確的資訊。


    A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

    ShortSection的摘要,供人解讀。Text summary of the section, for human interpretation
    Comments

    文件Profile可能會定義應在敘述中呈現哪些內容,以確保臨床安全。


    Document profiles may define what content should be represented in the narrative to ensure clinical safety.

    Control0..1
    This element is affected by the following invariants: cmp-1
    TypeNarrative
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    50. Composition.section.entry
    Definition

    指向那些提供小節中敘述內容的實際resource的參照


    A reference to the actual resource from which the narrative in the section is derived.

    Short提供一個連結用於參照或查看支持此小節內容的資料A reference to data that supports this section
    Comments

    如果清單中沒有條目,則 建議應該(SHOULD) 提供 emptyReason。


    If there are no entries in the list, an emptyReason SHOULD be provided.

    Control50..*
    This element is affected by the following invariants: cmp-2
    TypeReference(Resource)
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    SlicingThis element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • profile @ resolve()
    • 52. Composition.section.entry:Practitioner
      Slice NamePractitioner
      Definition

      指向那些提供小節中敘述內容的實際resource的參照


      A reference to the actual resource from which the narrative in the section is derived.

      Short支援這個section的資料之參照A reference to data that supports this section
      Comments

      如果清單中沒有條目,則 建議應該(SHOULD) 提供 emptyReason。


      If there are no entries in the list, an emptyReason SHOULD be provided.

      Control10..1*
      This element is affected by the following invariants: cmp-2
      TypeReference(醫療影像及報告-醫事人員基本資料, Resource)
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      54. Composition.section.entry:Condition
      Slice NameCondition
      Definition

      指向那些提供小節中敘述內容的實際resource的參照


      A reference to the actual resource from which the narrative in the section is derived.

      Short支援這個section的資料之參照A reference to data that supports this section
      Comments

      如果清單中沒有條目,則 建議應該(SHOULD) 提供 emptyReason。


      If there are no entries in the list, an emptyReason SHOULD be provided.

      Control10..1*
      This element is affected by the following invariants: cmp-2
      TypeReference(醫療影像及報告-病史, Resource)
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      56. Composition.section.entry:Observation
      Slice NameObservation
      Definition

      指向那些提供小節中敘述內容的實際resource的參照


      A reference to the actual resource from which the narrative in the section is derived.

      Short支援這個section的資料之參照A reference to data that supports this section
      Comments

      如果清單中沒有條目,則 建議應該(SHOULD) 提供 emptyReason。


      If there are no entries in the list, an emptyReason SHOULD be provided.

      Control10..1*
      This element is affected by the following invariants: cmp-2
      TypeReference(醫療影像及報告-影像檢驗報告, Resource)
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      58. Composition.section.entry:DiagnosticReport
      Slice NameDiagnosticReport
      Definition

      指向那些提供小節中敘述內容的實際resource的參照


      A reference to the actual resource from which the narrative in the section is derived.

      Short支援這個section的資料之參照A reference to data that supports this section
      Comments

      如果清單中沒有條目,則 建議應該(SHOULD) 提供 emptyReason。


      If there are no entries in the list, an emptyReason SHOULD be provided.

      Control10..1*
      This element is affected by the following invariants: cmp-2
      TypeReference(DiagnosticReport Image, Resource)
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      60. Composition.section.entry:ImagingStudy
      Slice NameImagingStudy
      Definition

      指向那些提供小節中敘述內容的實際resource的參照


      A reference to the actual resource from which the narrative in the section is derived.

      Short支援這個section的資料之參照A reference to data that supports this section
      Comments

      如果清單中沒有條目,則 建議應該(SHOULD) 提供 emptyReason。


      If there are no entries in the list, an emptyReason SHOULD be provided.

      Control10..1*
      This element is affected by the following invariants: cmp-2
      TypeReference(醫療影像及報告-醫學影像內容, Resource)
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Invariantsele-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. Composition
      Definition

      一組與健康照護相關的資訊,這些訊息被組合成一個單一的邏輯套件,提供一個單一的連貫的意義陳述,建立自己的上下文,並且提供有關於是誰做出陳述的臨床認證。

      Short醫療影像及報告Composition
      Comments

      雖然此規範的重點在於特定於病人的臨床聲明,但此resource也可適用於其他與健康照護相關的聲明,如研究方案設計、醫療發票和其他不必然與特定於病人或臨床相關的活動。

      Control0..*
      Is Modifierfalse
      Summaryfalse
      Invariantsdom-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. Composition.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Composition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

      Control0..1
      Typeid
      Is Modifierfalse
      Summarytrue
      4. Composition.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Composition Resource的metadata
      Control0..1
      TypeMeta
      Is Modifierfalse
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      6. Composition.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。

      Control0..1
      Typeuri
      Is Modifiertrue 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 ValueThis primitive element may be present, or absent, or replaced by an extension
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      8. Composition.language
      Definition

      編寫此resource的基礎語言

      Short用以表述Composition 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)。

      Control0..1
      BindingThe codes SHOULD be taken from CommonLanguages
      (preferred to http://hl7.org/fhir/ValueSet/languages)

      人類語言;鼓勵使用所綁定值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。

      Additional BindingsPurpose
      AllLanguagesMax Binding
      Typecode
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summaryfalse
      Example<br/><b>Value</b>:zh-TW
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      10. Composition.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。

      ShortComposition 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。

      Control0..1
      TypeNarrative
      Is Modifierfalse
      Summaryfalse
      Alternate Namesnarrative, html, xhtml, display
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      12. Composition.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

      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。

      Control0..*
      TypeResource
      Is Modifierfalse
      Summaryfalse
      Alternate Namesinline resources, anonymous resources, contained resources
      14. Composition.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污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

      Control0..*
      TypeExtension
      Is Modifierfalse
      Summaryfalse
      Invariantsele-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. Composition.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污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

      Control0..*
      TypeExtension
      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
      Summaryfalse
      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操作性。更多訊息,請參見修飾用的資料項目擴充之定義

      Invariantsele-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. Composition.identifier
      Definition

      與版本無關的Composition識別碼。隨著時間的推移,該識別碼將保持不變。

      Short不分版本的臨床文件架構(Composition)識別碼。
      Comments

      類似於 CDA 中的 ClinicalDocument/setId。請參閱resource定義中的討論,了解它們之間的關係。

      NoteThis is a business identifier, not a resource identifier (see discussion)
      Control0..1
      TypeIdentifier
      Is Modifierfalse
      Must Supporttrue
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      20. Composition.status
      Definition

      此composition的工作流程/臨床狀態。狀態是指文件的臨床狀態的標識。

      Shortregistered | partial | preliminary | final | amended | corrected +
      Comments

      如果一個composition被標記為撤回(withdraw),那麼該系列中的composition/文件或者此composition或文件系列中的資料,若未被明確標記為(該撤回)不可信的情況下,則不應向用戶展示。「錯誤輸入 (entered-in-error)標籤是此composition為何被標記為修飾用資料項目(modifier)的原因。 某些報告工作流程要求最終文件的原始敘述永不更改;意即只能添加新的敘述。composition resource 沒有明確的狀態(status)來明確註明是否適用此業務規則。如有需要,這將透過擴充來處理。

      Control1..1
      BindingThe codes SHALL be taken from CompositionStatus
      (required to http://hl7.org/fhir/ValueSet/composition-status|4.0.1)

      Composition的工作流程/臨床狀態;應填入所綁定值集中的其中一個代碼。

      Typecode
      Is Modifiertrue 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 ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      需要能夠標記為臨時(interim)、修改(amended)或撤回(withdrawn)的composition或文件。

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      22. Composition.type
      Definition

      指定特定類型的composition(如病史和體檢、出院摘要、病程紀錄)。這通常等同於製作composition的目的。

      ShortComposition的種類(如果可能請使用LOINC)
      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.

      Control1..1
      This element is affected by the following invariants: ele-1
      BindingUnless not suitable, these codes SHALL be taken from FHIRDocumentTypeCodes
      (extensible to http://hl7.org/fhir/ValueSet/doc-typecodes)

      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。

      TypeCodeableConcept(TW CodeableConcept)
      Is Modifierfalse
      Must Supporttrue
      Requirements

      描述composition的關鍵metadata資料項目,用於查詢/篩選。

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      24. Composition.type.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。
      Control0..1
      Typestring
      Is Modifierfalse
      XML FormatIn the XML format, this property is represented as an attribute.
      Summaryfalse
      26. Composition.type.extension
      Definition

      擴充的資料項目

      Short擴充的資料項目
      Control0..*
      TypeExtension
      Is Modifierfalse
      Summaryfalse
      Invariantsele-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())
      SlicingThis element introduces a set of slices on Composition.type.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • value @ url
      • 28. Composition.type.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,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。

        Control1..1
        This element is affected by the following invariants: ele-1
        TypeCoding(TW Coding)
        Is Modifierfalse
        Must Supporttrue
        Requirements

        允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。

        Pattern Value{
          "system" : "http://loinc.org",
          "code" : "18782-3",
          "display" : "Radiology Study observation (narrative)"
        }
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        30. Composition.type.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。

        Control0..1
        Typestring
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Must Supporttrue
        Summarytrue
        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。

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        32. Composition.category
        Definition

        composition類型的分類 - 有助於索引和查詢。這可能是由 Composition Type 中指定的代碼隱含或衍生出來的。

        ShortComposition的分類
        Comments

        "這是來自XDS/MHD的metadata欄位"。

        Control0..*
        This element is affected by the following invariants: ele-1
        BindingUnless not suitable, these codes SHALL be taken from DocumentClassValueSet
        (extensible to http://hl7.org/fhir/ValueSet/document-classcodes)

        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。

        TypeCodeableConcept(TW CodeableConcept)
        Is Modifierfalse
        Requirements

        幫助人類在檢視composition或規範文件時評估composition是否感興趣。

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        34. Composition.subject
        Definition

        composition是關於誰或什麼的。composition可以是關於一個人(病人或醫護人員)、一個設備(如機器),甚至是一群對象(如關於一群牲畜的文件,或一群有共同曝露的病人)。

        ShortComposition是關於誰和/或什麼
        Comments

        對於臨床文件來說,這通常是指病人。

        Control1..1
        TypeReference(醫療影像及報告-病患基本資料)
        Is Modifierfalse
        Must Supporttrue
        Summarytrue
        Requirements

        查詢composition的基本metadata,指明compoisition/文件的作者和/或內容。

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        36. Composition.encounter
        Definition

        描述與該文件相關的臨床就醫事件或照護類型。

        ShortComposition的情境
        Control0..1
        TypeReference(醫療影像及報告-醫囑時間)
        Is Modifierfalse
        Summarytrue
        Requirements

        為composition提供情境並支持查詢。

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        38. Composition.date
        Definition

        composition編輯時間,即作者最後一次邏輯上更改composition的時間。

        ShortComposition編輯時間
        Comments

        composition上的最後修改日期可能在文件被證明日期之後而未更改。這意味著修改過的文件上的日期是修改日期,而非原始撰寫之日期。

        Control1..1
        TypedateTime
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Must Supporttrue
        Summarytrue
        Requirements

        dateTime 用於追蹤、組織版本和查詢。請注意:這是創作此版本Composition的時間。打包成文檔時,Bundle.timestamp 是打包日期。

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        40. Composition.author
        Definition

        指明誰對composition中的資訊負責,而不一定是誰輸入了它。

        Short什麼機構撰寫此醫療影像及報告
        Control1..1
        TypeReference(醫療影像及報告-醫事機構基本資料)
        Is Modifierfalse
        Must Supporttrue
        Summarytrue
        Requirements

        指明誰對內容負責

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        42. Composition.title
        Definition

        composition的正式可讀標籤

        Short醫療影像及報告
        Comments

        對於許多composition來說,標題與文本或 Composition.type 的顯示名稱相同(如 「會診﹙consultation﹚」或 「病程紀錄﹙progress note﹚」)。請注意:CDA 並不強制要求標題,但目前還沒有發現省略標題有用的情況,因此在此強制要求標題。歡迎在試用區間對這一要求提出反饋意見。

        Control1..1
        Typestring
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Must Supporttrue
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        44. Composition.confidentiality
        Definition

        具體說明Composition保密等級的代碼

        Short根據特定技術領域的定義
        Comments

        此資料項目的確切使用,以及與高度敏感文件相關的執行和問題超出了基本規範的範圍,並委託給實作Profiles(見安全小節)。 此資料項目被標記為修飾用,因為高度機密的文件不能被當作非機密文件處理。

        Control0..1
        BindingThe codes SHALL be taken from v3.ConfidentialityClassification (2014-03-26)
        (required to http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26)

        應填入所綁定值集中的其中一個代碼。

        Typecode
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        46. Composition.attester
        Definition

        證明composition/文件準確無誤的參與者

        Short證明Composition的準確性
        Comments

        每位參與者只需每位證明者只列一次

        Control0..1
        TypeBackboneElement
        Is Modifierfalse
        Must Supporttrue
        Summaryfalse
        Requirements

        指明對composition內容準確性的責任

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        48. Composition.attester.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。
        Control0..1
        Typestring
        Is Modifierfalse
        XML FormatIn the XML format, this property is represented as an attribute.
        Summaryfalse
        50. Composition.attester.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。

        Control0..*
        TypeExtension
        Is Modifierfalse
        Summaryfalse
        Invariantsele-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())
        52. Composition.attester.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。

        Control0..*
        TypeExtension
        Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
        Summarytrue
        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

        Invariantsele-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())
        54. Composition.attester.mode
        Definition

        認證者提供的認證類型

        Shortpersonal | professional | legal | official
        Control1..1
        BindingThe codes SHALL be taken from CompositionAttestationMode
        (required to http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1)

        認證者提供的認證類型;應填入所綁定值集中的其中一個代碼。

        Typecode
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Summaryfalse
        Requirements

        指明認證的權威程度

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        56. Composition.attester.time
        Definition

        當composition被該方證實的時間

        ShortComposition何時被證明
        Control0..1
        TypedateTime
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Must Supporttrue
        Summaryfalse
        Requirements

        指明composition中的資訊何時被認為是準確的。(自那時起可能發生了變化)。

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        58. Composition.attester.party
        Definition

        誰以指定的方式證明了此composition

        Short誰證明這個Composition
        Control1..1
        TypeReference(醫療影像及報告-醫事機構基本資料)
        Is Modifierfalse
        Must Supporttrue
        Summaryfalse
        Requirements

        指明由誰承擔composition內容準確性的責任

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        60. Composition.custodian
        Definition

        指明負責持續維護和存取composition/文件資訊的機構或團體

        Short維護Composition的機構
        Comments

        當此文件是衍生自composition時非常有用。它提供了如何獲取文件的最新版本的指導。這是可選項,因為有時編寫系統並不知道可以根據情境推斷。不過,在處理派生文件時,了解這一資訊非常重要,因此鼓勵提供一個保管者。

        Control0..1
        TypeReference(TW Core Organization)
        Is Modifierfalse
        Must Supporttrue
        Summarytrue
        Requirements

        指明在哪裡可以找到當前版本、在哪裡可以報告問題等

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        62. Composition.relatesTo
        Definition

        此composition與其他已有的composition或文件之間的關係

        Short與其他Composition/文件之間的關係
        Comments

        要參照(使用 relatesTo)「document」type的 Bundle 或其他只有識別碼的 Composition,請使用帶有識別碼的 resourceReference。

        Control0..*
        TypeBackboneElement
        Is Modifierfalse
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        64. Composition.relatesTo.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。
        Control0..1
        Typestring
        Is Modifierfalse
        XML FormatIn the XML format, this property is represented as an attribute.
        Summaryfalse
        66. Composition.relatesTo.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。

        Control0..*
        TypeExtension
        Is Modifierfalse
        Summaryfalse
        Invariantsele-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())
        68. Composition.relatesTo.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。

        Control0..*
        TypeExtension
        Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
        Summarytrue
        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

        Invariantsele-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. Composition.relatesTo.code
        Definition

        此composition與另一個compoisition或文件的關系類型

        Shortreplaces | transforms | signs | appends
        Comments

        如果此文件附加了另一個文件,那麼如果不存取參照的文件,就無法完全理解此文件。

        Control1..1
        BindingThe codes SHALL be taken from DocumentRelationshipType
        (required to http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1)

        檔案之間的關係型別;應填入所綁定值集中的其中一個代碼。

        Typecode
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        72. Composition.relatesTo.target[x]
        Definition

        此關係的目標composition/文件

        Short此關係的目標文件
        Control1..1
        TypeChoice of: Identifier, Reference(Composition)
        [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
        Is Modifierfalse
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        74. Composition.event
        Definition

        記錄的臨床服務,例如:結腸鏡檢查或闌尾切除術。

        Short正在記錄的臨床服務
        Comments

        事件需要與類型資料項目保持一致,但如果需求,也可以提供更多的詳細資訊。

        Control0..*
        TypeBackboneElement
        Is Modifierfalse
        Summarytrue
        Requirements

        為composition提供情境背景,並在描述事件的resource和為描述事件而創建的composition之間建立連結。

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        76. Composition.event.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。
        Control0..1
        Typestring
        Is Modifierfalse
        XML FormatIn the XML format, this property is represented as an attribute.
        Summaryfalse
        78. Composition.event.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。

        Control0..*
        TypeExtension
        Is Modifierfalse
        Summaryfalse
        Invariantsele-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())
        80. Composition.event.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。

        Control0..*
        TypeExtension
        Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
        Summarytrue
        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

        Invariantsele-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())
        82. Composition.event.code
        Definition

        一個概念可能透過正式參照專門術語或本體論來定義,或者可以由文字提供。

        Short此代碼表代表了正在被記錄的主要臨床行為
        Comments

        一個事件可以進一步專門化 typeCode 中固有的行為,例如:當它僅僅是「處置報告」,而該處置是「結腸鏡檢查」。如果包含一個或多個事件,它們 必須沒有(SHALL NOT) 與 classCode、practiceSettingCode 或 typeCode 中固有的值相衝突,因為這樣的衝突會造成模糊不清的情況。這個簡短的代碼清單提供用作某些類型查詢的關鍵字。

        Control0..*
        This element is affected by the following invariants: ele-1
        BindingFor example codes, see v3 Code System ActCode
        (example to http://terminology.hl7.org/ValueSet/v3-ActCode)

        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。

        TypeCodeableConcept(TW CodeableConcept)
        Is Modifierfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        84. Composition.event.period
        Definition

        此文件涵蓋的時間區間,這並不是聲明此文件是這一個時間區間的完整代表,而只是表明它記錄了這段時間內發生的事件。

        Short文件所涵蓋的時間區間
        Control0..1
        TypePeriod
        Is Modifierfalse
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        86. Composition.event.detail
        Definition

        它描述了正在被記錄的主要臨床活動,比如說進行一次結腸鏡檢查或是闌尾切除手術。在某些情況下,這些臨床事件本身就包含在其typeCode中,例如:在「病史與體檢報告」中,所記錄的過程就必然是進行「病史與體檢」的行為。這些臨床事件可以以代碼的形式被記錄,或者作為對其他resource的參照。

        Short在描述被記錄下來的事件,這些事件可以是以代碼的形式、參考資料的形式,或者兩者都有的形式來呈現。
        Comments

        事件可以進一步細化類型編碼中的固有行為,例如,事件只是程序報告,而程序是結腸鏡檢查。如果包含一個或多個事件,它們不得與類別編碼、診療設置編碼或類型代碼中固有的值相衝 突,因為這樣的衝突會造成模稜兩可的情況。本編碼簡表可用作某些類型查詢的關鍵詞。

        Control0..*
        TypeReference(Resource)
        Is Modifierfalse
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        88. Composition.section
        Definition

        構成composition的各小節

        ShortSection的標籤(例如:目錄)
        Control0..*
        TypeBackboneElement
        Is Modifierfalse
        Must Supporttrue
        Summaryfalse
        Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
        cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
        ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        90. Composition.section.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。
        Control0..1
        Typestring
        Is Modifierfalse
        XML FormatIn the XML format, this property is represented as an attribute.
        Summaryfalse
        92. Composition.section.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。

        Control0..*
        TypeExtension
        Is Modifierfalse
        Summaryfalse
        Invariantsele-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())
        94. Composition.section.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。

        Control0..*
        TypeExtension
        Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
        Summarytrue
        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

        Invariantsele-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())
        96. Composition.section.title
        Definition

        此特定小節的標籤。這將是文件呈現內容的一部分,通常用於建立目錄。

        Short小節標籤(例如:目錄ToC)
        Comments

        標題為人類讀者指明小節。標題必須與作為 section.content 參照目標的resource的敘述一致。通常章節 建議應該(SHOULD) 有標題,但在某些文件中,這可能是不必要的或不適當的。通常情況下,當一個小節有其自己足夠區分的標題的子小節,或只有單一小節的文件時,就會這樣。大多數IG會要求小節標題是必填的資料項目。

        Control0..1
        Typestring
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Summaryfalse
        Requirements

        不同類型的文件常常會有標準化的小節標題,這些標題為人們提供如何組織文件的指引。

        Alternate Namesheader, label, caption
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        98. Composition.section.code
        Definition

        一個用於指明小節中所含內容種類的代碼,這個代碼必須與小節的標題相一致。

        Short小節分類(建議)
        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.

        Control1..1
        This element is affected by the following invariants: ele-1
        BindingUnless not suitable, these codes SHALL be taken from DocumentSectionCodes
        (extensible to http://hl7.org/fhir/ValueSet/doc-section-codes)

        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。

        TypeCodeableConcept(TW CodeableConcept)
        Is Modifierfalse
        Must Supporttrue
        Requirements

        提供給文件中主題的標籤是標準化的,並且可以被電腦程式識別和處理。

        Pattern Value{
          "coding" : [{
            "system" : "http://loinc.org",
            "code" : "30954-2",
            "display" : "Relevant diagnostic tests/laboratory data Narrative"
          }]
        }
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        100. Composition.section.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。
        Control0..1
        Typestring
        Is Modifierfalse
        XML FormatIn the XML format, this property is represented as an attribute.
        Summaryfalse
        102. Composition.section.code.extension
        Definition

        擴充的資料項目

        Short擴充的資料項目
        Control0..*
        TypeExtension
        Is Modifierfalse
        Summaryfalse
        Invariantsele-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())
        SlicingThis element introduces a set of slices on Composition.section.code.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
        • value @ url
        • 104. Composition.section.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,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。

          Control1..*
          This element is affected by the following invariants: ele-1
          TypeCoding(TW Coding)
          Is Modifierfalse
          Must Supporttrue
          Requirements

          允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          106. Composition.section.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。

          Control0..1
          Typestring
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Must Supporttrue
          Summarytrue
          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。

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          108. Composition.section.author
          Definition

          指明誰對小節中的資訊負責,而不一定是誰輸入了它。

          Short誰和/或什麼人撰寫了該小節
          Control0..*
          TypeReference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, TW Core Patient, Device, RelatedPerson)
          Is Modifierfalse
          Summaryfalse
          Requirements

          指明誰對內容負責

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          110. Composition.section.focus
          Definition

          當小節的實際焦點不是composition描述的對象,而是代表與對象相關的某事物或某人時,例如:(對於病人對象)配偶、父母、胎兒或捐贈者。如果沒有指定焦點,則假定焦點為父小節的焦點,或者對於Composition本身中的小節,為Composition的對象。具有焦點的小節只 必須(SHALL) 包含對象(病人、對象、焦點等)與小節焦點相匹配的resources,或者是沒有對象的resources(少數resources)。

          Short當小節與composition描述的對象無關時,此小節是關於誰/什麼。
          Comments

          通常,文件中的小節是關於該文件的描述對象,無論是病人、一群病人、位置、設備或其他。對於某些種類的文件,有些小節實際上包含有關的實體資料。典型的例子包括新生兒出院病摘中關於母親的小節,或者家族病史文件中關於每個家庭成員的小節,當然還有很多其他例子。

          Control0..1
          TypeReference(Resource)
          Is Modifierfalse
          Summaryfalse
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          112. Composition.section.text
          Definition

          一個供人閱讀的敘述,包含小節的核實內容,用以展現resource的內容供人類閱讀。這段敘述不需要涵蓋所有結構化的資料,但必須包含足夠的細節,確保僅透過閱讀這段敘述的人能夠在臨床上獲得安全且準確的資訊。

          ShortSection的摘要,供人解讀。
          Comments

          文件Profile可能會定義應在敘述中呈現哪些內容,以確保臨床安全。

          Control0..1
          This element is affected by the following invariants: cmp-1
          TypeNarrative
          Is Modifierfalse
          Must Supporttrue
          Summaryfalse
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          114. Composition.section.mode
          Definition

          條目清單是如何準備的 - 它是一個適合持續維護的工作清單,還是代表從另一個來源截取的項目清單的快照,或者是一個準備好的清單,在該清單中,項目可能被標記為已添加、修改或刪除。

          Short適用於此小節的處理模式
          Comments

          這個資料項目被標記為修飾用,是因為不應將變更清單(a change list)誤解為完整清單(a complete list)。

          Control0..1
          BindingThe codes SHALL be taken from ListMode
          (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1)

          應填入所綁定值集中的其中一個代碼。

          Typecode
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Summaryfalse
          Requirements

          小節有多種使用方式,因此必須清楚地了解如何安全地使用其中的條目。

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          116. Composition.section.orderedBy
          Definition

          指定應用於小節條目的項目順序

          Short小節條目的順序
          Comments

          應用程式 建議應該(SHOULD) 按照給定的順序來顯示有序清單,但也可以允許用戶按照他們自己的偏好進行重新排序。如果沒有明確指定順序,則該順序是不確定的,雖然清單可能仍有某種排列順序。

          Control0..1
          This element is affected by the following invariants: ele-1
          BindingThe codes SHOULD be taken from ListOrderCodes
          (preferred to http://hl7.org/fhir/ValueSet/list-order)

          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。

          TypeCodeableConcept(TW CodeableConcept)
          Is Modifierfalse
          Requirements

          這對於展示和呈現是重要的,清單可能會進行排序,以便將重要的資訊放在前面,或將相關的條目分組。

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          118. Composition.section.entry
          Definition

          指向那些提供小節中敘述內容的實際resource的參照

          Short提供一個連結用於參照或查看支持此小節內容的資料
          Comments

          如果清單中沒有條目,則 建議應該(SHOULD) 提供 emptyReason。

          Control5..*
          This element is affected by the following invariants: cmp-2
          TypeReference(Resource)
          Is Modifierfalse
          Must Supporttrue
          Summaryfalse
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          SlicingThis element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators:
          • profile @ resolve()
          • 120. Composition.section.entry:Practitioner
            Slice NamePractitioner
            Definition

            指向那些提供小節中敘述內容的實際resource的參照

            Short支援這個section的資料之參照
            Comments

            如果清單中沒有條目,則 建議應該(SHOULD) 提供 emptyReason。

            Control1..1
            This element is affected by the following invariants: cmp-2
            TypeReference(醫療影像及報告-醫事人員基本資料)
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            122. Composition.section.entry:Condition
            Slice NameCondition
            Definition

            指向那些提供小節中敘述內容的實際resource的參照

            Short支援這個section的資料之參照
            Comments

            如果清單中沒有條目,則 建議應該(SHOULD) 提供 emptyReason。

            Control1..1
            This element is affected by the following invariants: cmp-2
            TypeReference(醫療影像及報告-病史)
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            124. Composition.section.entry:Observation
            Slice NameObservation
            Definition

            指向那些提供小節中敘述內容的實際resource的參照

            Short支援這個section的資料之參照
            Comments

            如果清單中沒有條目,則 建議應該(SHOULD) 提供 emptyReason。

            Control1..1
            This element is affected by the following invariants: cmp-2
            TypeReference(醫療影像及報告-影像檢驗報告)
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            126. Composition.section.entry:DiagnosticReport
            Slice NameDiagnosticReport
            Definition

            指向那些提供小節中敘述內容的實際resource的參照

            Short支援這個section的資料之參照
            Comments

            如果清單中沒有條目,則 建議應該(SHOULD) 提供 emptyReason。

            Control1..1
            This element is affected by the following invariants: cmp-2
            TypeReference(DiagnosticReport Image)
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            128. Composition.section.entry:ImagingStudy
            Slice NameImagingStudy
            Definition

            指向那些提供小節中敘述內容的實際resource的參照

            Short支援這個section的資料之參照
            Comments

            如果清單中沒有條目,則 建議應該(SHOULD) 提供 emptyReason。

            Control1..1
            This element is affected by the following invariants: cmp-2
            TypeReference(醫療影像及報告-醫學影像內容)
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            130. Composition.section.emptyReason
            Definition

            如果小節為空,則說明清單為空的原因。一個空的小節通常有一些文字說明空的原因。

            Short為什麼此小節是空的原因
            Comments

            當一個小節是空的,其空白的原因對於理解該小節非常重要。需要注意的是,這個代碼是用於當整個小節的內容都沒有被包括時,它並不適用於個別項目被省略的情形,若為個別項目被省略的情況,開發者可以考慮在該條目中添加文字說明或標記。

            Control0..1
            This element is affected by the following invariants: ele-1
            BindingThe codes SHOULD be taken from ListEmptyReasons
            (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason)

            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。

            TypeCodeableConcept(TW CodeableConcept)
            Is Modifierfalse
            Requirements

            允許捕捉像是「不存在」或「未詢問」這樣的情況,這對於大多數清單來說可能很重要。

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            132. Composition.section.section
            Definition

            此小節中嵌套的小節

            Short嵌套的小節
            Comments

            嵌套小節主要是為了幫助讀者快速找到文件中的特定內容

            Control0..*
            This element is affected by the following invariants: cmp-1
            TypeSeettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
            Is Modifierfalse
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))