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: 出院病摘_醫學影像檢查(ImagingStudy)

Official URL: https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/DMSImagingStudy Version: 0.1.0
Draft as of 2024-08-23 Computable Name: DischargeMedicalSummaryImagingStudy

此Profiles用於描述出院病摘中的醫學影像檢查

Usage:

Formal Views of Profile Content

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

This structure is derived from TWCoreImagingStudy

NameFlagsCard.TypeDescription & Constraintsdoco
.. ImagingStudy 0..* TWCoreImagingStudy 在單一檢查中產生的一組影像【一個或多個系列(series)的參照影像】
... status S 1..1 code registered | available | cancelled | entered-in-error | unknown
Fixed Value: available
... subject 1..1 Reference(Device | Group | 出院病摘-病人基本資料) 醫學影像檢查對象
... started 1..1 dateTime 醫學影像檢查開始時間。[應填入至出院病摘醫療影像檢查Imaging Study]
.... text 1..1 string 醫療影像檢查發生的原因描述。[應填入至出院病摘醫療影像檢查Imaging Study]
... reasonReference S 0..* Reference(TW Core Condition | TW Core Observation Laboratory Result | Media | TW Core DiagnosticReport | DocumentReference) 紀錄儲存醫療影像檢查檔案的位置
... series 0..* BackboneElement 檢查的身體部位
.... modality 1..1 Coding 醫療影像檢查
..... display S 1..1 string Display of the terminology system。[應填入至出院病摘醫療影像檢查Imaging Study]
.... bodySite S 0..1 Coding 檢查的身體部位
..... display S 1..1 string 檢查的身體部位描述。[應填入至出院病摘醫療影像檢查Imaging Study]

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ImagingStudy 0..* TWCoreImagingStudy 在單一檢查中產生的一組影像【一個或多個系列(series)的參照影像】
... implicitRules ?!Σ 0..1 uri 創建此內容所依據的一組規則
... modifierExtension ?! 0..* Extension 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。
... identifier SΣ 0..* Identifier 整項影像檢查的識別碼
... modality SΣ 0..* Coding 列出所有系列中用於實際影像獲取的儀器類型
Binding: AcquisitionModality (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... subject SΣ 1..1 Reference(Device | Group | 出院病摘-病人基本資料) 醫學影像檢查對象
... started SΣ 1..1 dateTime 醫學影像檢查開始時間。[應填入至出院病摘醫療影像檢查Imaging Study]
Example General: 2011-01-01T11:01:20+03:00
... procedureCode S 0..* CodeableConceptTW 執行的處置代碼
Binding: http://www.rsna.org/RadLex_Playbook.aspx (extensible): 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。


.... Slices for coding S 0..* CodingTW 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。
Slice: Unordered, Open by pattern:$this
..... coding:radLex-radiology-lexicon S 0..1 CodingTW 應填入所綁定值集中的其中一個代碼。
Binding: http://www.rsna.org/RadLex_Playbook.aspx (required)
..... coding:icd10-pcs-2021 S 0..1 CodingTW 應填入所綁定值集中的其中一個代碼。
Binding: 臺灣健保署2021年中文版ICD-10-PCS值集 (required)
.... text SΣ 0..1 string 概念的文字表示法
... reasonCode S 0..* CodeableConceptTW 醫療影像檢查發生的原因描述
Binding: ProcedureReasonCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


.... coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼
.... text SΣ 1..1 string 醫療影像檢查發生的原因描述。[應填入至出院病摘醫療影像檢查Imaging Study]
... reasonReference SΣ 0..* Reference(TW Core Condition | TW Core Observation Laboratory Result | Media | TW Core DiagnosticReport | DocumentReference) 紀錄儲存醫療影像檢查檔案的位置
... series SΣ 0..* BackboneElement 檢查的身體部位
.... modifierExtension ?!Σ 0..* Extension 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。
.... uid SΣ 1..1 id 此系列的DICOM系列實例UID
Example General: 2.16.124.113543.6003.2588828330.45298.17418.2723805630
.... modality SΣ 1..1 Coding 醫療影像檢查
Binding: AcquisitionModality (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

..... display SΣ 1..1 string Display of the terminology system。[應填入至出院病摘醫療影像檢查Imaging Study]
.... bodySite SΣ 0..1 Coding 檢查的身體部位
Binding: SNOMEDCTBodyStructures (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

..... display SΣ 1..1 string 檢查的身體部位描述。[應填入至出院病摘醫療影像檢查Imaging Study]
.... instance S 0..* BackboneElement 系列中的一個SOP實例
..... modifierExtension ?!Σ 0..* Extension 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。
..... uid S 1..1 id DICOM SOP實例的UID
Example General: 2.16.124.113543.6003.189642796.63084.16748.2599092903
..... sopClass S 1..1 Coding DICOM class 類型
Binding: http://dicom.nema.org/medical/dicom/current/output/chtml/part04/sect_B.5.html#table_B.5-1 (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ImagingStudy.statusrequiredFixed Value: available
http://hl7.org/fhir/ValueSet/imagingstudy-status|4.0.1
from the FHIR Standard
ImagingStudy.modalityextensibleAcquisitionModality
http://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_29.html
ImagingStudy.procedureCodeextensiblehttp://www.rsna.org/RadLex_Playbook.aspx
http://www.rsna.org/RadLex_Playbook.aspx
ImagingStudy.procedureCode.coding:radLex-radiology-lexiconrequiredhttp://www.rsna.org/RadLex_Playbook.aspx
http://www.rsna.org/RadLex_Playbook.aspx
ImagingStudy.procedureCode.coding:icd10-pcs-2021requiredTW2021ICD10PCS
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw
ImagingStudy.reasonCodeextensibleProcedureReasonCodes
http://hl7.org/fhir/ValueSet/procedure-reason
from the FHIR Standard
ImagingStudy.series.modalityextensibleAcquisitionModality
http://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_29.html
ImagingStudy.series.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
ImagingStudy.series.instance.sopClassextensiblehttp://dicom.nema.org/medical/dicom/current/output/chtml/part04/sect_B.5.html#table_B.5-1
http://dicom.nema.org/medical/dicom/current/output/chtml/part04/sect_B.5.html#table_B.5-1

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorImagingStudyIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorImagingStudyIf 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-4errorImagingStudyIf 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-5errorImagingStudyIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceImagingStudyA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ImagingStudy 0..* TWCoreImagingStudy 在單一檢查中產生的一組影像【一個或多個系列(series)的參照影像】
... id Σ 0..1 id 不重複的ID用以識別儲存在特定FHIR Server中的ImagingStudy紀錄,通常又稱為邏輯性ID。
... meta Σ 0..1 Meta 此ImagingStudy Resource的metadata
... implicitRules ?!Σ 0..1 uri 創建此內容所依據的一組規則
... language 0..1 code 用以表述ImagingStudy Resource內容的語言。
Binding: CommonLanguages (preferred): 人類語言;鼓勵使用CommonLanguages代碼表中的代碼,但不強制一定要使用此代碼表,你也可使用其他代碼表的代碼或單純以文字表示。

Additional BindingsPurpose
AllLanguages Max Binding

Example Value: zh-TW
... text 0..1 Narrative ImagingStudy Resource之內容摘要以供人閱讀
... contained 0..* Resource 內嵌的(contained)、行內的Resources
... extension 0..* Extension 擴充的資料項目
... modifierExtension ?! 0..* Extension 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。
... identifier SΣ 0..* Identifier 整項影像檢查的識別碼
... status ?!SΣ 1..1 code registered | available | cancelled | entered-in-error | unknown
Binding: ImagingStudyStatus (required): 影像檢查的當前狀態;應填入所綁定值集中的其中一個代碼。


Fixed Value: available
... modality SΣ 0..* Coding 列出所有系列中用於實際影像獲取的儀器類型
Binding: AcquisitionModality (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... subject SΣ 1..1 Reference(Device | Group | 出院病摘-病人基本資料) 醫學影像檢查對象
... encounter Σ 0..1 Reference(TW Core Encounter) 與此影像檢查有關的就醫事件(Encounter)
... started SΣ 1..1 dateTime 醫學影像檢查開始時間。[應填入至出院病摘醫療影像檢查Imaging Study]
Example General: 2011-01-01T11:01:20+03:00
... basedOn Σ 0..* Reference(CarePlan | ServiceRequest | Appointment | AppointmentResponse | Task) 要求執行此影像檢查的依據
... referrer Σ 0..1 Reference(TW Core Practitioner | TW Core PractitionerRole) 轉診醫師
... interpreter Σ 0..* Reference(TW Core Practitioner | TW Core PractitionerRole) 誰解讀了影像
... endpoint Σ 0..* Reference(Endpoint) 影像檢查存取的端點(endpoint)
... numberOfSeries Σ 0..1 unsignedInt 影像檢查相關Series的數量
... numberOfInstances Σ 0..1 unsignedInt 影像檢查相關Instances的數量
... procedureReference Σ 0..1 Reference(TW Core Procedure) 所執行的處置(Procedure)參照
... procedureCode S 0..* CodeableConceptTW 執行的處置代碼
Binding: http://www.rsna.org/RadLex_Playbook.aspx (extensible): 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。


.... id 0..1 string 唯一可識別ID,以供資料項目間相互參照。
.... extension 0..* Extension 擴充的資料項目
Slice: Unordered, Open by value:url
.... Slices for coding S 0..* CodingTW 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。
Slice: Unordered, Open by pattern:$this
..... coding:radLex-radiology-lexicon S 0..1 CodingTW 應填入所綁定值集中的其中一個代碼。
Binding: http://www.rsna.org/RadLex_Playbook.aspx (required)
..... coding:icd10-pcs-2021 S 0..1 CodingTW 應填入所綁定值集中的其中一個代碼。
Binding: 臺灣健保署2021年中文版ICD-10-PCS值集 (required)
.... text SΣ 0..1 string 概念的文字表示法
... location Σ 0..1 Reference(Location) 影像檢查發生的地點
... reasonCode S 0..* CodeableConceptTW 醫療影像檢查發生的原因描述
Binding: ProcedureReasonCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


.... id 0..1 string 唯一可識別ID,以供資料項目間相互參照。
.... extension 0..* Extension 擴充的資料項目
Slice: Unordered, Open by value:url
.... coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼
.... text SΣ 1..1 string 醫療影像檢查發生的原因描述。[應填入至出院病摘醫療影像檢查Imaging Study]
... reasonReference SΣ 0..* Reference(TW Core Condition | TW Core Observation Laboratory Result | Media | TW Core DiagnosticReport | DocumentReference) 紀錄儲存醫療影像檢查檔案的位置
... note Σ 0..* Annotation 用戶自定義的評論
... description Σ 0..1 string 機構產生的描述
... series SΣ 0..* BackboneElement 檢查的身體部位
.... id 0..1 string 唯一可識別ID,以供資料項目間相互參照。
.... extension 0..* Extension 擴充的資料項目
.... modifierExtension ?!Σ 0..* Extension 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。
.... uid SΣ 1..1 id 此系列的DICOM系列實例UID
Example General: 2.16.124.113543.6003.2588828330.45298.17418.2723805630
.... number Σ 0..1 unsignedInt 此系列的數字識別碼
Example General: 3
.... modality SΣ 1..1 Coding 醫療影像檢查
Binding: AcquisitionModality (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ 0..1 uri Identity of the terminology system
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 0..1 code Symbol in syntax defined by the system
..... display SΣ 1..1 string Display of the terminology system。[應填入至出院病摘醫療影像檢查Imaging Study]
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... description Σ 0..1 string 對此系列的一個簡短且易於閱讀的摘要
Example General: CT Surview 180
.... numberOfInstances Σ 0..1 unsignedInt 此Series相關Instances的數量
.... endpoint Σ 0..* Reference(Endpoint) 此系列的存取端點
.... bodySite SΣ 0..1 Coding 檢查的身體部位
Binding: SNOMEDCTBodyStructures (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ 0..1 uri Identity of the terminology system
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 0..1 code Symbol in syntax defined by the system
..... display SΣ 1..1 string 檢查的身體部位描述。[應填入至出院病摘醫療影像檢查Imaging Study]
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... laterality Σ 0..1 Coding 身體部位的側性
Binding: Laterality (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

.... specimen Σ 0..* Reference(TW Core Specimen) 要進行影像檢查的檢體
.... started Σ 0..1 dateTime 此系列何時開始的
.... performer Σ 0..* BackboneElement 誰執行了此系列
..... id 0..1 string 唯一可識別ID,以供資料項目間相互參照。
..... extension 0..* Extension 擴充的資料項目
..... modifierExtension ?!Σ 0..* Extension 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。
..... function 0..1 CodeableConceptTW 執行的類型
Binding: ImagingStudySeriesPerformerFunction (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

..... actor Σ 1..1 Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | CareTeam | TW Core Patient | Device | RelatedPerson) 誰執行了此系列
.... instance S 0..* BackboneElement 系列中的一個SOP實例
..... id 0..1 string 唯一可識別ID,以供資料項目間相互參照。
..... extension 0..* Extension 擴充的資料項目
..... modifierExtension ?!Σ 0..* Extension 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。
..... uid S 1..1 id DICOM SOP實例的UID
Example General: 2.16.124.113543.6003.189642796.63084.16748.2599092903
..... sopClass S 1..1 Coding DICOM class 類型
Binding: http://dicom.nema.org/medical/dicom/current/output/chtml/part04/sect_B.5.html#table_B.5-1 (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

..... number 0..1 unsignedInt 此系列中該實例的序號
Example General: 1
..... title 0..1 string 實例的描述

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ImagingStudy.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ImagingStudy.statusrequiredFixed Value: available
http://hl7.org/fhir/ValueSet/imagingstudy-status|4.0.1
from the FHIR Standard
ImagingStudy.modalityextensibleAcquisitionModality
http://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_29.html
ImagingStudy.procedureCodeextensiblehttp://www.rsna.org/RadLex_Playbook.aspx
http://www.rsna.org/RadLex_Playbook.aspx
ImagingStudy.procedureCode.coding:radLex-radiology-lexiconrequiredhttp://www.rsna.org/RadLex_Playbook.aspx
http://www.rsna.org/RadLex_Playbook.aspx
ImagingStudy.procedureCode.coding:icd10-pcs-2021requiredTW2021ICD10PCS
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw
ImagingStudy.reasonCodeextensibleProcedureReasonCodes
http://hl7.org/fhir/ValueSet/procedure-reason
from the FHIR Standard
ImagingStudy.series.modalityextensibleAcquisitionModality
http://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_29.html
ImagingStudy.series.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
ImagingStudy.series.lateralityextensibleLaterality
http://hl7.org/fhir/ValueSet/bodysite-laterality
from the FHIR Standard
ImagingStudy.series.performer.functionextensibleImagingStudySeriesPerformerFunction
http://hl7.org/fhir/ValueSet/series-performer-function
from the FHIR Standard
ImagingStudy.series.instance.sopClassextensiblehttp://dicom.nema.org/medical/dicom/current/output/chtml/part04/sect_B.5.html#table_B.5-1
http://dicom.nema.org/medical/dicom/current/output/chtml/part04/sect_B.5.html#table_B.5-1

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorImagingStudyIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorImagingStudyIf 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-4errorImagingStudyIf 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-5errorImagingStudyIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceImagingStudyA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from TWCoreImagingStudy

Summary

Mandatory: 1 element(3 nested mandatory elements)
Must-Support: 5 elements
Fixed: 1 element

Structures

This structure refers to these other structures:

Differential View

This structure is derived from TWCoreImagingStudy

NameFlagsCard.TypeDescription & Constraintsdoco
.. ImagingStudy 0..* TWCoreImagingStudy 在單一檢查中產生的一組影像【一個或多個系列(series)的參照影像】
... status S 1..1 code registered | available | cancelled | entered-in-error | unknown
Fixed Value: available
... subject 1..1 Reference(Device | Group | 出院病摘-病人基本資料) 醫學影像檢查對象
... started 1..1 dateTime 醫學影像檢查開始時間。[應填入至出院病摘醫療影像檢查Imaging Study]
.... text 1..1 string 醫療影像檢查發生的原因描述。[應填入至出院病摘醫療影像檢查Imaging Study]
... reasonReference S 0..* Reference(TW Core Condition | TW Core Observation Laboratory Result | Media | TW Core DiagnosticReport | DocumentReference) 紀錄儲存醫療影像檢查檔案的位置
... series 0..* BackboneElement 檢查的身體部位
.... modality 1..1 Coding 醫療影像檢查
..... display S 1..1 string Display of the terminology system。[應填入至出院病摘醫療影像檢查Imaging Study]
.... bodySite S 0..1 Coding 檢查的身體部位
..... display S 1..1 string 檢查的身體部位描述。[應填入至出院病摘醫療影像檢查Imaging Study]

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ImagingStudy 0..* TWCoreImagingStudy 在單一檢查中產生的一組影像【一個或多個系列(series)的參照影像】
... implicitRules ?!Σ 0..1 uri 創建此內容所依據的一組規則
... modifierExtension ?! 0..* Extension 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。
... identifier SΣ 0..* Identifier 整項影像檢查的識別碼
... modality SΣ 0..* Coding 列出所有系列中用於實際影像獲取的儀器類型
Binding: AcquisitionModality (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... subject SΣ 1..1 Reference(Device | Group | 出院病摘-病人基本資料) 醫學影像檢查對象
... started SΣ 1..1 dateTime 醫學影像檢查開始時間。[應填入至出院病摘醫療影像檢查Imaging Study]
Example General: 2011-01-01T11:01:20+03:00
... procedureCode S 0..* CodeableConceptTW 執行的處置代碼
Binding: http://www.rsna.org/RadLex_Playbook.aspx (extensible): 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。


.... Slices for coding S 0..* CodingTW 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。
Slice: Unordered, Open by pattern:$this
..... coding:radLex-radiology-lexicon S 0..1 CodingTW 應填入所綁定值集中的其中一個代碼。
Binding: http://www.rsna.org/RadLex_Playbook.aspx (required)
..... coding:icd10-pcs-2021 S 0..1 CodingTW 應填入所綁定值集中的其中一個代碼。
Binding: 臺灣健保署2021年中文版ICD-10-PCS值集 (required)
.... text SΣ 0..1 string 概念的文字表示法
... reasonCode S 0..* CodeableConceptTW 醫療影像檢查發生的原因描述
Binding: ProcedureReasonCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


.... coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼
.... text SΣ 1..1 string 醫療影像檢查發生的原因描述。[應填入至出院病摘醫療影像檢查Imaging Study]
... reasonReference SΣ 0..* Reference(TW Core Condition | TW Core Observation Laboratory Result | Media | TW Core DiagnosticReport | DocumentReference) 紀錄儲存醫療影像檢查檔案的位置
... series SΣ 0..* BackboneElement 檢查的身體部位
.... modifierExtension ?!Σ 0..* Extension 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。
.... uid SΣ 1..1 id 此系列的DICOM系列實例UID
Example General: 2.16.124.113543.6003.2588828330.45298.17418.2723805630
.... modality SΣ 1..1 Coding 醫療影像檢查
Binding: AcquisitionModality (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

..... display SΣ 1..1 string Display of the terminology system。[應填入至出院病摘醫療影像檢查Imaging Study]
.... bodySite SΣ 0..1 Coding 檢查的身體部位
Binding: SNOMEDCTBodyStructures (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

..... display SΣ 1..1 string 檢查的身體部位描述。[應填入至出院病摘醫療影像檢查Imaging Study]
.... instance S 0..* BackboneElement 系列中的一個SOP實例
..... modifierExtension ?!Σ 0..* Extension 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。
..... uid S 1..1 id DICOM SOP實例的UID
Example General: 2.16.124.113543.6003.189642796.63084.16748.2599092903
..... sopClass S 1..1 Coding DICOM class 類型
Binding: http://dicom.nema.org/medical/dicom/current/output/chtml/part04/sect_B.5.html#table_B.5-1 (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ImagingStudy.statusrequiredFixed Value: available
http://hl7.org/fhir/ValueSet/imagingstudy-status|4.0.1
from the FHIR Standard
ImagingStudy.modalityextensibleAcquisitionModality
http://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_29.html
ImagingStudy.procedureCodeextensiblehttp://www.rsna.org/RadLex_Playbook.aspx
http://www.rsna.org/RadLex_Playbook.aspx
ImagingStudy.procedureCode.coding:radLex-radiology-lexiconrequiredhttp://www.rsna.org/RadLex_Playbook.aspx
http://www.rsna.org/RadLex_Playbook.aspx
ImagingStudy.procedureCode.coding:icd10-pcs-2021requiredTW2021ICD10PCS
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw
ImagingStudy.reasonCodeextensibleProcedureReasonCodes
http://hl7.org/fhir/ValueSet/procedure-reason
from the FHIR Standard
ImagingStudy.series.modalityextensibleAcquisitionModality
http://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_29.html
ImagingStudy.series.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
ImagingStudy.series.instance.sopClassextensiblehttp://dicom.nema.org/medical/dicom/current/output/chtml/part04/sect_B.5.html#table_B.5-1
http://dicom.nema.org/medical/dicom/current/output/chtml/part04/sect_B.5.html#table_B.5-1

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorImagingStudyIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorImagingStudyIf 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-4errorImagingStudyIf 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-5errorImagingStudyIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceImagingStudyA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ImagingStudy 0..* TWCoreImagingStudy 在單一檢查中產生的一組影像【一個或多個系列(series)的參照影像】
... id Σ 0..1 id 不重複的ID用以識別儲存在特定FHIR Server中的ImagingStudy紀錄,通常又稱為邏輯性ID。
... meta Σ 0..1 Meta 此ImagingStudy Resource的metadata
... implicitRules ?!Σ 0..1 uri 創建此內容所依據的一組規則
... language 0..1 code 用以表述ImagingStudy Resource內容的語言。
Binding: CommonLanguages (preferred): 人類語言;鼓勵使用CommonLanguages代碼表中的代碼,但不強制一定要使用此代碼表,你也可使用其他代碼表的代碼或單純以文字表示。

Additional BindingsPurpose
AllLanguages Max Binding

Example Value: zh-TW
... text 0..1 Narrative ImagingStudy Resource之內容摘要以供人閱讀
... contained 0..* Resource 內嵌的(contained)、行內的Resources
... extension 0..* Extension 擴充的資料項目
... modifierExtension ?! 0..* Extension 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。
... identifier SΣ 0..* Identifier 整項影像檢查的識別碼
... status ?!SΣ 1..1 code registered | available | cancelled | entered-in-error | unknown
Binding: ImagingStudyStatus (required): 影像檢查的當前狀態;應填入所綁定值集中的其中一個代碼。


Fixed Value: available
... modality SΣ 0..* Coding 列出所有系列中用於實際影像獲取的儀器類型
Binding: AcquisitionModality (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... subject SΣ 1..1 Reference(Device | Group | 出院病摘-病人基本資料) 醫學影像檢查對象
... encounter Σ 0..1 Reference(TW Core Encounter) 與此影像檢查有關的就醫事件(Encounter)
... started SΣ 1..1 dateTime 醫學影像檢查開始時間。[應填入至出院病摘醫療影像檢查Imaging Study]
Example General: 2011-01-01T11:01:20+03:00
... basedOn Σ 0..* Reference(CarePlan | ServiceRequest | Appointment | AppointmentResponse | Task) 要求執行此影像檢查的依據
... referrer Σ 0..1 Reference(TW Core Practitioner | TW Core PractitionerRole) 轉診醫師
... interpreter Σ 0..* Reference(TW Core Practitioner | TW Core PractitionerRole) 誰解讀了影像
... endpoint Σ 0..* Reference(Endpoint) 影像檢查存取的端點(endpoint)
... numberOfSeries Σ 0..1 unsignedInt 影像檢查相關Series的數量
... numberOfInstances Σ 0..1 unsignedInt 影像檢查相關Instances的數量
... procedureReference Σ 0..1 Reference(TW Core Procedure) 所執行的處置(Procedure)參照
... procedureCode S 0..* CodeableConceptTW 執行的處置代碼
Binding: http://www.rsna.org/RadLex_Playbook.aspx (extensible): 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。


.... id 0..1 string 唯一可識別ID,以供資料項目間相互參照。
.... extension 0..* Extension 擴充的資料項目
Slice: Unordered, Open by value:url
.... Slices for coding S 0..* CodingTW 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。
Slice: Unordered, Open by pattern:$this
..... coding:radLex-radiology-lexicon S 0..1 CodingTW 應填入所綁定值集中的其中一個代碼。
Binding: http://www.rsna.org/RadLex_Playbook.aspx (required)
..... coding:icd10-pcs-2021 S 0..1 CodingTW 應填入所綁定值集中的其中一個代碼。
Binding: 臺灣健保署2021年中文版ICD-10-PCS值集 (required)
.... text SΣ 0..1 string 概念的文字表示法
... location Σ 0..1 Reference(Location) 影像檢查發生的地點
... reasonCode S 0..* CodeableConceptTW 醫療影像檢查發生的原因描述
Binding: ProcedureReasonCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


.... id 0..1 string 唯一可識別ID,以供資料項目間相互參照。
.... extension 0..* Extension 擴充的資料項目
Slice: Unordered, Open by value:url
.... coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼
.... text SΣ 1..1 string 醫療影像檢查發生的原因描述。[應填入至出院病摘醫療影像檢查Imaging Study]
... reasonReference SΣ 0..* Reference(TW Core Condition | TW Core Observation Laboratory Result | Media | TW Core DiagnosticReport | DocumentReference) 紀錄儲存醫療影像檢查檔案的位置
... note Σ 0..* Annotation 用戶自定義的評論
... description Σ 0..1 string 機構產生的描述
... series SΣ 0..* BackboneElement 檢查的身體部位
.... id 0..1 string 唯一可識別ID,以供資料項目間相互參照。
.... extension 0..* Extension 擴充的資料項目
.... modifierExtension ?!Σ 0..* Extension 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。
.... uid SΣ 1..1 id 此系列的DICOM系列實例UID
Example General: 2.16.124.113543.6003.2588828330.45298.17418.2723805630
.... number Σ 0..1 unsignedInt 此系列的數字識別碼
Example General: 3
.... modality SΣ 1..1 Coding 醫療影像檢查
Binding: AcquisitionModality (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ 0..1 uri Identity of the terminology system
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 0..1 code Symbol in syntax defined by the system
..... display SΣ 1..1 string Display of the terminology system。[應填入至出院病摘醫療影像檢查Imaging Study]
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... description Σ 0..1 string 對此系列的一個簡短且易於閱讀的摘要
Example General: CT Surview 180
.... numberOfInstances Σ 0..1 unsignedInt 此Series相關Instances的數量
.... endpoint Σ 0..* Reference(Endpoint) 此系列的存取端點
.... bodySite SΣ 0..1 Coding 檢查的身體部位
Binding: SNOMEDCTBodyStructures (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ 0..1 uri Identity of the terminology system
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 0..1 code Symbol in syntax defined by the system
..... display SΣ 1..1 string 檢查的身體部位描述。[應填入至出院病摘醫療影像檢查Imaging Study]
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... laterality Σ 0..1 Coding 身體部位的側性
Binding: Laterality (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

.... specimen Σ 0..* Reference(TW Core Specimen) 要進行影像檢查的檢體
.... started Σ 0..1 dateTime 此系列何時開始的
.... performer Σ 0..* BackboneElement 誰執行了此系列
..... id 0..1 string 唯一可識別ID,以供資料項目間相互參照。
..... extension 0..* Extension 擴充的資料項目
..... modifierExtension ?!Σ 0..* Extension 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。
..... function 0..1 CodeableConceptTW 執行的類型
Binding: ImagingStudySeriesPerformerFunction (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

..... actor Σ 1..1 Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | CareTeam | TW Core Patient | Device | RelatedPerson) 誰執行了此系列
.... instance S 0..* BackboneElement 系列中的一個SOP實例
..... id 0..1 string 唯一可識別ID,以供資料項目間相互參照。
..... extension 0..* Extension 擴充的資料項目
..... modifierExtension ?!Σ 0..* Extension 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。
..... uid S 1..1 id DICOM SOP實例的UID
Example General: 2.16.124.113543.6003.189642796.63084.16748.2599092903
..... sopClass S 1..1 Coding DICOM class 類型
Binding: http://dicom.nema.org/medical/dicom/current/output/chtml/part04/sect_B.5.html#table_B.5-1 (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

..... number 0..1 unsignedInt 此系列中該實例的序號
Example General: 1
..... title 0..1 string 實例的描述

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ImagingStudy.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ImagingStudy.statusrequiredFixed Value: available
http://hl7.org/fhir/ValueSet/imagingstudy-status|4.0.1
from the FHIR Standard
ImagingStudy.modalityextensibleAcquisitionModality
http://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_29.html
ImagingStudy.procedureCodeextensiblehttp://www.rsna.org/RadLex_Playbook.aspx
http://www.rsna.org/RadLex_Playbook.aspx
ImagingStudy.procedureCode.coding:radLex-radiology-lexiconrequiredhttp://www.rsna.org/RadLex_Playbook.aspx
http://www.rsna.org/RadLex_Playbook.aspx
ImagingStudy.procedureCode.coding:icd10-pcs-2021requiredTW2021ICD10PCS
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw
ImagingStudy.reasonCodeextensibleProcedureReasonCodes
http://hl7.org/fhir/ValueSet/procedure-reason
from the FHIR Standard
ImagingStudy.series.modalityextensibleAcquisitionModality
http://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_29.html
ImagingStudy.series.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
ImagingStudy.series.lateralityextensibleLaterality
http://hl7.org/fhir/ValueSet/bodysite-laterality
from the FHIR Standard
ImagingStudy.series.performer.functionextensibleImagingStudySeriesPerformerFunction
http://hl7.org/fhir/ValueSet/series-performer-function
from the FHIR Standard
ImagingStudy.series.instance.sopClassextensiblehttp://dicom.nema.org/medical/dicom/current/output/chtml/part04/sect_B.5.html#table_B.5-1
http://dicom.nema.org/medical/dicom/current/output/chtml/part04/sect_B.5.html#table_B.5-1

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorImagingStudyIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorImagingStudyIf 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-4errorImagingStudyIf 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-5errorImagingStudyIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceImagingStudyA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from TWCoreImagingStudy

Summary

Mandatory: 1 element(3 nested mandatory elements)
Must-Support: 5 elements
Fixed: 1 element

Structures

This structure refers to these other structures:

 

Other representations of profile: CSV, Excel, Schematron