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: DiagnosticReport Image

Official URL: https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/DiagnosticReport-Image Version: 0.1.0
Draft as of 2024-01-31 Computable Name: ImageDiagnosticReport

此Profile說明本IG如何進一步定義FHIR的DiagnosticReport Resource以呈現影像報告之內容

Usage:

Formal Views of Profile Content

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

This structure is derived from DiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport 診斷報告—由請求資訊、不可被中斷的一個或一系列結果（atomic results）、影像、解釋以及格式化報告所組成。
... identifier S 1..1 Identifier 報告的業務用識別碼。[應填入於醫學影像報告檢查單號Accession No.]
.... system S 1..1 uri 機構識別碼（identifier）的命名空間（namespace）
.... value S 1..1 string 檢查單號(Accession No.)
... status S 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category S 1..1 CodeableConcept Service category
Binding: ImagingStudy Category Type (required)
.... coding 1..* Coding 由專門術語系統（terminology system）定義的代碼
..... system 1..1 uri 專門術語系統（terminology system）的識別
..... code 1..1 code 系統定義的語法之符號
..... display 1..1 string 由系統定義的表示法
... subject S 1..1 Reference(醫療影像及報告-病患基本資料) 報告的對象—通常但不總是病人
... encounter S 0..1 Reference(醫療影像及報告-醫囑時間) 請求醫療資源時的健康照護事件
... effective[x] S 1..1 dateTime, Period 與臨床相關的時間／報告的時段。[應填入醫學影像報告確認報告時間Verification Time]
... issued S 0..1 instant 此版本完成的日期時間
... performer S 1..* Reference(醫療影像及報告-醫事人員基本資料 | 醫療影像及報告-醫事機構基本資料) 對診斷服務負責者。[應連結醫學影像報告報告醫師姓名Verification Physician]
... resultsInterpreter S 0..* Reference(醫療影像及報告-醫事人員基本資料 | 醫療影像及報告-醫事機構基本資料) 主要結果的解釋者
... specimen S 0..* Reference(Specimen) 此報告所依據的檢體
... result S 1..* Reference(醫療影像及報告-影像檢驗報告) 診斷結果(Finding)
... imagingStudy S 1..* Reference(醫療影像及報告-醫學影像內容) 參照至與診斷報告相關的成像之全部細節
... media S 0..* BackboneElement 與此報告相關的關鍵影像
.... comment S 0..1 string 關於影像的意見（例如：解釋）。
.... link S 1..1 Reference(Media) 參照的影像來源
... conclusion S 1..1 string 診斷結果的臨床結論（interpretation/impression）。[應填入醫學影像報告報告結果Records. Total]
... conclusionCode S 0..* CodeableConcept 診斷結果的臨床結論的代碼，此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。
... presentedForm 0..* Attachment 已發佈的整個報告

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryrequiredImageCategory
https://twcore.mohw.gov.tw/ig/emr/ValueSet/ImageCategory
from this IG
DiagnosticReport.codepreferredProcedureCode (a valid code from ICD-10-PCS-2021)
https://twcore.mohw.gov.tw/ig/emr/ValueSet/ICD-10-procedurecode
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport 診斷報告—由請求資訊、不可被中斷的一個或一系列結果（atomic results）、影像、解釋以及格式化報告所組成。
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier 報告的業務用識別碼。[應填入於醫學影像報告檢查單號Accession No.]
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... system SΣ 1..1 uri 機構識別碼（identifier）的命名空間（namespace）
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string 檢查單號(Accession No.)
Example General: 123456
... category SΣ 1..1 CodeableConcept Service category
Binding: ImagingStudy Category Type (required)
.... coding Σ 1..* Coding 由專門術語系統（terminology system）定義的代碼
..... system Σ 1..1 uri 專門術語系統（terminology system）的識別
..... code Σ 1..1 code 系統定義的語法之符號
..... display Σ 1..1 string 由系統定義的表示法
... code SΣ 1..1 CodeableConcept 此診斷報告的名稱／代碼。[應填入於醫學影像報告疾病診斷Diagnosis ICD Code]
Binding: ICD-10-PCS-2021 (preferred)
... subject SΣ 1..1 Reference(醫療影像及報告-病患基本資料) 報告的對象—通常但不總是病人
... encounter SΣ 0..1 Reference(醫療影像及報告-醫囑時間) 請求醫療資源時的健康照護事件
... effective[x] SΣ 1..1 與臨床相關的時間／報告的時段。[應填入醫學影像報告確認報告時間Verification Time]
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 0..1 instant 此版本完成的日期時間
... performer SΣ 1..* Reference(醫療影像及報告-醫事人員基本資料 | 醫療影像及報告-醫事機構基本資料) 對診斷服務負責者。[應連結醫學影像報告報告醫師姓名Verification Physician]
... resultsInterpreter SΣ 0..* Reference(醫療影像及報告-醫事人員基本資料 | 醫療影像及報告-醫事機構基本資料) 主要結果的解釋者
... specimen S 0..* Reference(Specimen) 此報告所依據的檢體
... result S 1..* Reference(醫療影像及報告-影像檢驗報告) 診斷結果(Finding)
... imagingStudy S 1..* Reference(醫療影像及報告-醫學影像內容) 參照至與診斷報告相關的成像之全部細節
... media SΣ 0..* BackboneElement 與此報告相關的關鍵影像
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... comment S 0..1 string 關於影像的意見（例如：解釋）。
.... link SΣ 1..1 Reference(Media) 參照的影像來源
... conclusion S 1..1 string 診斷結果的臨床結論（interpretation/impression）。[應填入醫學影像報告報告結果Records. Total]
... conclusionCode S 0..* CodeableConcept 診斷結果的臨床結論的代碼，此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


... presentedForm 0..* Attachment 已發佈的整個報告

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DiagnosticReport.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryrequiredImageCategory
https://twcore.mohw.gov.tw/ig/emr/ValueSet/ImageCategory
from this IG
DiagnosticReport.codepreferredProcedureCode (a valid code from ICD-10-PCS-2021)
https://twcore.mohw.gov.tw/ig/emr/ValueSet/ICD-10-procedurecode
from this IG
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA 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
.. DiagnosticReport 0..* DiagnosticReport 診斷報告—由請求資訊、不可被中斷的一個或一系列結果（atomic results）、影像、解釋以及格式化報告所組成。
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier 報告的業務用識別碼。[應填入於醫學影像報告檢查單號Accession No.]
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

.... system SΣ 1..1 uri 機構識別碼（identifier）的命名空間（namespace）
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string 檢查單號(Accession No.)
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... basedOn 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... status ?!SΣ 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category SΣ 1..1 CodeableConcept Service category
Binding: ImagingStudy Category Type (required)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 1..* Coding 由專門術語系統（terminology system）定義的代碼
..... 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 1..1 uri 專門術語系統（terminology system）的識別
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 1..1 code 系統定義的語法之符號
..... display Σ 1..1 string 由系統定義的表示法
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept 此診斷報告的名稱／代碼。[應填入於醫學影像報告疾病診斷Diagnosis ICD Code]
Binding: ICD-10-PCS-2021 (preferred)
... subject SΣ 1..1 Reference(醫療影像及報告-病患基本資料) 報告的對象—通常但不總是病人
... encounter SΣ 0..1 Reference(醫療影像及報告-醫囑時間) 請求醫療資源時的健康照護事件
... effective[x] SΣ 1..1 與臨床相關的時間／報告的時段。[應填入醫學影像報告確認報告時間Verification Time]
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 0..1 instant 此版本完成的日期時間
... performer SΣ 1..* Reference(醫療影像及報告-醫事人員基本資料 | 醫療影像及報告-醫事機構基本資料) 對診斷服務負責者。[應連結醫學影像報告報告醫師姓名Verification Physician]
... resultsInterpreter SΣ 0..* Reference(醫療影像及報告-醫事人員基本資料 | 醫療影像及報告-醫事機構基本資料) 主要結果的解釋者
... specimen S 0..* Reference(Specimen) 此報告所依據的檢體
... result S 1..* Reference(醫療影像及報告-影像檢驗報告) 診斷結果(Finding)
... imagingStudy S 1..* Reference(醫療影像及報告-醫學影像內容) 參照至與診斷報告相關的成像之全部細節
... media SΣ 0..* BackboneElement 與此報告相關的關鍵影像
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... comment S 0..1 string 關於影像的意見（例如：解釋）。
.... link SΣ 1..1 Reference(Media) 參照的影像來源
... conclusion S 1..1 string 診斷結果的臨床結論（interpretation/impression）。[應填入醫學影像報告報告結果Records. Total]
... conclusionCode S 0..* CodeableConcept 診斷結果的臨床結論的代碼，此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


... presentedForm 0..* Attachment 已發佈的整個報告

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DiagnosticReport.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
DiagnosticReport.identifier.typeextensibleIdentifier Type Codes
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryrequiredImageCategory
https://twcore.mohw.gov.tw/ig/emr/ValueSet/ImageCategory
from this IG
DiagnosticReport.codepreferredProcedureCode (a valid code from ICD-10-PCS-2021)
https://twcore.mohw.gov.tw/ig/emr/ValueSet/ICD-10-procedurecode
from this IG
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA 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()

Differential View

This structure is derived from DiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport 診斷報告—由請求資訊、不可被中斷的一個或一系列結果（atomic results）、影像、解釋以及格式化報告所組成。
... identifier S 1..1 Identifier 報告的業務用識別碼。[應填入於醫學影像報告檢查單號Accession No.]
.... system S 1..1 uri 機構識別碼（identifier）的命名空間（namespace）
.... value S 1..1 string 檢查單號(Accession No.)
... status S 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category S 1..1 CodeableConcept Service category
Binding: ImagingStudy Category Type (required)
.... coding 1..* Coding 由專門術語系統（terminology system）定義的代碼
..... system 1..1 uri 專門術語系統（terminology system）的識別
..... code 1..1 code 系統定義的語法之符號
..... display 1..1 string 由系統定義的表示法
... subject S 1..1 Reference(醫療影像及報告-病患基本資料) 報告的對象—通常但不總是病人
... encounter S 0..1 Reference(醫療影像及報告-醫囑時間) 請求醫療資源時的健康照護事件
... effective[x] S 1..1 dateTime, Period 與臨床相關的時間／報告的時段。[應填入醫學影像報告確認報告時間Verification Time]
... issued S 0..1 instant 此版本完成的日期時間
... performer S 1..* Reference(醫療影像及報告-醫事人員基本資料 | 醫療影像及報告-醫事機構基本資料) 對診斷服務負責者。[應連結醫學影像報告報告醫師姓名Verification Physician]
... resultsInterpreter S 0..* Reference(醫療影像及報告-醫事人員基本資料 | 醫療影像及報告-醫事機構基本資料) 主要結果的解釋者
... specimen S 0..* Reference(Specimen) 此報告所依據的檢體
... result S 1..* Reference(醫療影像及報告-影像檢驗報告) 診斷結果(Finding)
... imagingStudy S 1..* Reference(醫療影像及報告-醫學影像內容) 參照至與診斷報告相關的成像之全部細節
... media S 0..* BackboneElement 與此報告相關的關鍵影像
.... comment S 0..1 string 關於影像的意見（例如：解釋）。
.... link S 1..1 Reference(Media) 參照的影像來源
... conclusion S 1..1 string 診斷結果的臨床結論（interpretation/impression）。[應填入醫學影像報告報告結果Records. Total]
... conclusionCode S 0..* CodeableConcept 診斷結果的臨床結論的代碼，此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。
... presentedForm 0..* Attachment 已發佈的整個報告

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryrequiredImageCategory
https://twcore.mohw.gov.tw/ig/emr/ValueSet/ImageCategory
from this IG
DiagnosticReport.codepreferredProcedureCode (a valid code from ICD-10-PCS-2021)
https://twcore.mohw.gov.tw/ig/emr/ValueSet/ICD-10-procedurecode
from this IG

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport 診斷報告—由請求資訊、不可被中斷的一個或一系列結果（atomic results）、影像、解釋以及格式化報告所組成。
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier 報告的業務用識別碼。[應填入於醫學影像報告檢查單號Accession No.]
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... system SΣ 1..1 uri 機構識別碼（identifier）的命名空間（namespace）
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string 檢查單號(Accession No.)
Example General: 123456
... category SΣ 1..1 CodeableConcept Service category
Binding: ImagingStudy Category Type (required)
.... coding Σ 1..* Coding 由專門術語系統（terminology system）定義的代碼
..... system Σ 1..1 uri 專門術語系統（terminology system）的識別
..... code Σ 1..1 code 系統定義的語法之符號
..... display Σ 1..1 string 由系統定義的表示法
... code SΣ 1..1 CodeableConcept 此診斷報告的名稱／代碼。[應填入於醫學影像報告疾病診斷Diagnosis ICD Code]
Binding: ICD-10-PCS-2021 (preferred)
... subject SΣ 1..1 Reference(醫療影像及報告-病患基本資料) 報告的對象—通常但不總是病人
... encounter SΣ 0..1 Reference(醫療影像及報告-醫囑時間) 請求醫療資源時的健康照護事件
... effective[x] SΣ 1..1 與臨床相關的時間／報告的時段。[應填入醫學影像報告確認報告時間Verification Time]
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 0..1 instant 此版本完成的日期時間
... performer SΣ 1..* Reference(醫療影像及報告-醫事人員基本資料 | 醫療影像及報告-醫事機構基本資料) 對診斷服務負責者。[應連結醫學影像報告報告醫師姓名Verification Physician]
... resultsInterpreter SΣ 0..* Reference(醫療影像及報告-醫事人員基本資料 | 醫療影像及報告-醫事機構基本資料) 主要結果的解釋者
... specimen S 0..* Reference(Specimen) 此報告所依據的檢體
... result S 1..* Reference(醫療影像及報告-影像檢驗報告) 診斷結果(Finding)
... imagingStudy S 1..* Reference(醫療影像及報告-醫學影像內容) 參照至與診斷報告相關的成像之全部細節
... media SΣ 0..* BackboneElement 與此報告相關的關鍵影像
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... comment S 0..1 string 關於影像的意見（例如：解釋）。
.... link SΣ 1..1 Reference(Media) 參照的影像來源
... conclusion S 1..1 string 診斷結果的臨床結論（interpretation/impression）。[應填入醫學影像報告報告結果Records. Total]
... conclusionCode S 0..* CodeableConcept 診斷結果的臨床結論的代碼，此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


... presentedForm 0..* Attachment 已發佈的整個報告

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DiagnosticReport.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryrequiredImageCategory
https://twcore.mohw.gov.tw/ig/emr/ValueSet/ImageCategory
from this IG
DiagnosticReport.codepreferredProcedureCode (a valid code from ICD-10-PCS-2021)
https://twcore.mohw.gov.tw/ig/emr/ValueSet/ICD-10-procedurecode
from this IG
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA 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
.. DiagnosticReport 0..* DiagnosticReport 診斷報告—由請求資訊、不可被中斷的一個或一系列結果（atomic results）、影像、解釋以及格式化報告所組成。
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier 報告的業務用識別碼。[應填入於醫學影像報告檢查單號Accession No.]
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

.... system SΣ 1..1 uri 機構識別碼（identifier）的命名空間（namespace）
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string 檢查單號(Accession No.)
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... basedOn 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... status ?!SΣ 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category SΣ 1..1 CodeableConcept Service category
Binding: ImagingStudy Category Type (required)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 1..* Coding 由專門術語系統（terminology system）定義的代碼
..... 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 1..1 uri 專門術語系統（terminology system）的識別
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 1..1 code 系統定義的語法之符號
..... display Σ 1..1 string 由系統定義的表示法
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept 此診斷報告的名稱／代碼。[應填入於醫學影像報告疾病診斷Diagnosis ICD Code]
Binding: ICD-10-PCS-2021 (preferred)
... subject SΣ 1..1 Reference(醫療影像及報告-病患基本資料) 報告的對象—通常但不總是病人
... encounter SΣ 0..1 Reference(醫療影像及報告-醫囑時間) 請求醫療資源時的健康照護事件
... effective[x] SΣ 1..1 與臨床相關的時間／報告的時段。[應填入醫學影像報告確認報告時間Verification Time]
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 0..1 instant 此版本完成的日期時間
... performer SΣ 1..* Reference(醫療影像及報告-醫事人員基本資料 | 醫療影像及報告-醫事機構基本資料) 對診斷服務負責者。[應連結醫學影像報告報告醫師姓名Verification Physician]
... resultsInterpreter SΣ 0..* Reference(醫療影像及報告-醫事人員基本資料 | 醫療影像及報告-醫事機構基本資料) 主要結果的解釋者
... specimen S 0..* Reference(Specimen) 此報告所依據的檢體
... result S 1..* Reference(醫療影像及報告-影像檢驗報告) 診斷結果(Finding)
... imagingStudy S 1..* Reference(醫療影像及報告-醫學影像內容) 參照至與診斷報告相關的成像之全部細節
... media SΣ 0..* BackboneElement 與此報告相關的關鍵影像
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... comment S 0..1 string 關於影像的意見（例如：解釋）。
.... link SΣ 1..1 Reference(Media) 參照的影像來源
... conclusion S 1..1 string 診斷結果的臨床結論（interpretation/impression）。[應填入醫學影像報告報告結果Records. Total]
... conclusionCode S 0..* CodeableConcept 診斷結果的臨床結論的代碼，此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


... presentedForm 0..* Attachment 已發佈的整個報告

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DiagnosticReport.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
DiagnosticReport.identifier.typeextensibleIdentifier Type Codes
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryrequiredImageCategory
https://twcore.mohw.gov.tw/ig/emr/ValueSet/ImageCategory
from this IG
DiagnosticReport.codepreferredProcedureCode (a valid code from ICD-10-PCS-2021)
https://twcore.mohw.gov.tw/ig/emr/ValueSet/ICD-10-procedurecode
from this IG
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA 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()

 

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