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: EncounterDS - Detailed Descriptions

Draft as of 2024-01-02

Definitions for the Encounter-DS resource profile.

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

0. Encounter
2. Encounter.identifier
NoteThis is a business identifier, not a resource identifier (see discussion)
4. Encounter.identifier.value
Definition

識別碼中通常與使用者有關的部分,在系統情境內是唯一的。 [原就醫識別碼]為醫療院所開立處方時之就醫識別碼 [就醫識別碼]為本次調劑處方所產製之就醫識別碼

Short唯一值。[應填入原就醫識別碼/就醫識別碼/健保卡就醫序號]
6. Encounter.class
Short病人就醫的分類。[應填入案件分類]
8. Encounter.type
Definition

就醫的特定型別(如電子郵件諮詢、手術日間照護、專業護理、復健)。 [歸屬]之填入內容建議為計畫案之開立處方,如:藥事照護計畫、戒菸門診、COVID-19…等特殊案件代碼

Short就醫的特定型別。[應填入歸屬]
10. Encounter.serviceType
Short服務的特定型別。[應填入科別 Department]
Control1..?
12. Encounter.subject
Control1..?
TypeReference(Group, 調劑單張-病人基本資料)
14. Encounter.period
Control1..?
16. Encounter.period.start
Definition

The start of the period. The boundary is inclusive. 等同開立處方日期 格式為西元YYYYMMDD

ShortStarting time with inclusive boundary。[應填入門診日期 OPD Date]
Control1..?
Must Supporttrue

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

0. Encounter
Definition

病人和健康照護服務提供者之間的互動,目的是提供健康照護服務或評估病人的健康狀況。


An interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.

Short提供病人服務的一種互動An interaction during which services are provided to the patient
Control0..*
Is Modifierfalse
Summaryfalse
Alternate NamesVisit
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. Encounter.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。通常這是對IG所定義之特殊規則及其他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交易夥伴所理解。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IG的參照,此IG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. Encounter.modifierExtension
Definition

可以用來表示不屬於此resource的基本定義的額外資訊,並修改包含它所內嵌(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的資訊。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。雖然任何實作者都可以定義一個擴充,但在定義擴充時 必須(SHALL) 滿足一組要求。處理resource的應用程式需要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

任何應用程式、專案或標準使用擴充時,都不應該帶有任何負面的聯想。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允許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。這樣做有助於促進可互操作性,因為無需禁止實作者使用擴充,想要瞭解更多資訊,請參見[修飾用的資料項目擴充之定義](http://hl7.org/fhir/R4/extensibility.html#modifierExtension)。


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. Encounter.identifier
Definition

此就醫事件的識別碼


Identifier(s) by which this encounter is known.

Short此就醫事件的識別碼Identifier(s) by which this encounter is known
NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Is Modifierfalse
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. Encounter.identifier.use
Definition

這個唯一識別碼(identifier)的用途


The purpose of this identifier.

Shortusual | official | temp | secondary | old (如果知道)usual | official | temp | secondary | old (If known)
Comments

應用程式可以假定一個識別碼是永久的,除非它明確說它是暫時的。


Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Control0..1
BindingThe codes SHALL be taken from IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1
(required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1)

如果知道,請說明此識別碼的用途;應填入所綁定值集中的其中一個代碼。


Identifies the purpose for this identifier, if known .

Typecode
Is Modifiertrue because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

允許從一組識別碼中為特定的使用情境選擇適當的識別碼


Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

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

建立值的命名空間-即一個描述一組值的唯一URL


Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

Short識別碼(identifier)的命名空間(namespace)The namespace for the identifier value
Comments

Identifier.system總是區分大小寫


Identifier.system is always case sensitive.

Control10..1
Typeuri
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

有許多識別碼的集合。為了進行兩個識別碼的對應,我們需要知道我們處理的是哪一組。系統指明了一個特定的唯一識別碼集。


There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

Example<br/><b>General</b>:http://www.acme.com/identifiers/patient
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. Encounter.identifier.value
Definition

識別碼中通常與使用者有關的部分,在系統情境內是唯一的。 [原就醫識別碼]為醫療院所開立處方時之就醫識別碼 [就醫識別碼]為本次調劑處方所產製之就醫識別碼


The portion of the identifier typically relevant to the user and which is unique within the context of the system.

Short唯一值。[應填入原就醫識別碼/就醫識別碼/健保卡就醫序號]The value that is unique
Comments

如果此值是一個完整的URI,那麼此系統 必須(SHALL) 是urn:ietf:rfc:3986。此值的主要目的是為了可運算的對應。因此,為了比較的目的,它可能會被正規化(例如:去除不重要的空白、破折號等)。一個為人顯示的格式化的值可以使用[Rendered Value](http://hl7.org/fhir/R4/extension-rendered-value.html)擴充來傳達。除非對Identifier.system的了解使處理者確信不區分大小寫的處理是安全的,否則Identifier.value應被視為區分大小寫。


If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Control10..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Example<br/><b>General</b>:123456
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
14. Encounter.status
Definition

planned | arrived | triaged | in-progress | onleave | finished | cancelled +.

Shortplanned | arrived | triaged | in-progress | onleave | finished | cancelled +
Comments

請注意,內部業務規則將決定於狀態(也包括類別)間可能發生的適當轉換。


Note that internal business rules will determine the appropriate transitions that may occur between statuses (and also classes).

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

就醫現況的代碼;應填入所綁定值集中的其中一個代碼


Current state of the encounter.

Typecode
Is Modifiertrue because This element is labeled 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
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
16. Encounter.class
Definition

病人就醫分類的概念,例如:門診病人、住院病人、急診病人、居家照護或其他因地方不同而產生的概念。


Concepts representing classification of patient encounter such as ambulatory (outpatient), inpatient, emergency, home health or others due to local variations.

Short病人就醫的分類。[應填入案件分類]Classification of patient encounter
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
BindingUnless not suitable, these codes SHALL be taken from ActEncounterCodehttp://terminology.hl7.org/ValueSet/v3-ActEncounterCode
(extensible to http://terminology.hl7.org/ValueSet/v3-ActEncounterCode)

就醫的分類;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 the encounter.

TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
18. Encounter.type
Definition

就醫的特定型別(如電子郵件諮詢、手術日間照護、專業護理、復健)。 [歸屬]之填入內容建議為計畫案之開立處方,如:藥事照護計畫、戒菸門診、COVID-19…等特殊案件代碼


Specific type of encounter (e.g. e-mail consultation, surgical day-care, skilled nursing, rehabilitation).

Short就醫的特定型別。[應填入歸屬]Specific type of encounter
Comments

由於有許多方法可以對就醫進行進一步的分類,所以這個資料項目的基數是0...* ,意即可不填寫或填寫數筆。


Since there are many ways to further classify encounters, this element is 0..*.

Control0..*
This element is affected by the following invariants: ele-1
BindingFor example codes, see EncounterTypehttp://hl7.org/fhir/ValueSet/encounter-type
(example to http://hl7.org/fhir/ValueSet/encounter-type)

就醫的型別;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。


The type of encounter.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. Encounter.serviceType
Definition

對所提供的服務進行廣泛的分類(如心臟科)


Broad categorization of the service that is to be provided (e.g. cardiology).

Short服務的特定型別。[應填入科別 Department]Specific type of service
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.

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 SNOMED CT + 臺灣健保署 + 衛福部統計處診療科別值集http://hl7.org/fhir/ValueSet/service-type
(extensible to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/health-department-sct-tw)

對提供的服務進行廣泛分類;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。


Broad categorization of the service that is to be provided.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. Encounter.subject
Definition

在場就醫的病人或實體集合(Group)


The patient or group present at the encounter.

Short在場就醫的病人或實體集合(Group)The patient or group present at the encounter
Comments

雖然就醫總是關於病人,但在所有的使用情境中,病人實際上可能並不為人所知及可能有一群病人是匿名的(例如:匿名酗酒者的團體治療中—就醫紀錄是以人數/工作人員數計費,而具體病人的情境並不重要);或者在獸醫照護中,一群羊接受治療(動物沒有被單獨追蹤)。


While the encounter is always about the patient, the patient might not actually be known in all contexts of use, and there may be a group of patients that could be anonymous (such as in a group therapy for Alcoholics Anonymous - where the recording of the encounter could be used for billing on the number of people/staff and not important to the context of the specific patients) or alternately in veterinary care a herd of sheep receiving treatment (where the animals are not individually tracked).

Control10..1
TypeReference(Group, 調劑單張-病人基本資料, Patient)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summarytrue
Alternate Namespatient
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. Encounter.participant
Definition

負責提供健康照護服務的人員名單


The list of people responsible for providing the service.

Short參與就醫的健康照護服務提供者之名單List of participants involved in the encounter
Control0..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. Encounter.participant.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())
28. Encounter.participant.type
Definition

參與者在病人就醫事件中的角色


Role of participant in encounter.

Short參與者在病人就醫事件中的角色Role of participant in encounter
Comments

參與者的型別表明個人如何參與病人的就醫事件。它包括非執業醫師的參與者,而對於執業醫師來說,這是為了描述在這次就醫中的活動型別(例如:住院醫生、主治醫生、翻譯者、諮詢醫生)。這與執業醫師的角色不同,執業醫師是功能性的角色,衍生自來僱用、教育、執照等。


The participant type indicates how an individual participates in an encounter. It includes non-practitioner participants, and for practitioners this is to describe the action type in the context of this encounter (e.g. Admitting Dr, Attending Dr, Translator, Consulting Dr). This is different to the practitioner roles which are functional roles, derived from terms of employment, education, licensing, etc.

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

參與者在病人就醫事件中的角色;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。


Role of participant in encounter.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. Encounter.participant.period
Definition

指定的參與者參與病人就醫的時段。這些時段可以是重疊的,也可以是整個就醫的時段的子集。


The period of time that the specified participant participated in the encounter. These can overlap or be sub-sets of the overall encounter's period.

Short參與者在病人就醫期間參與的時段Period of time during the encounter that the participant participated
Control0..1
TypePeriod
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. Encounter.participant.individual
Definition

除病人外,參與病人就醫事件的人。


Persons involved in the encounter other than the patient.

Short除病人外,參與病人就醫事件的人。Persons involved in the encounter other than the patient
Control0..1
TypeReference(TW Core Practitioner, TW Core PractitionerRole, RelatedPerson, Practitioner, PractitionerRole)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. Encounter.period
Definition

就醫的開始和結束時間


The start and end time of the encounter.

Short就醫的開始和結束時間The start and end time of the encounter
Comments

如果(尚)不知道,可以省略「期間」裡的結束日期時間。


If not (yet) known, the end of the Period may be omitted.

Control10..1
TypePeriod
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. Encounter.period.start
Definition

The start of the period. The boundary is inclusive. 等同開立處方日期 格式為西元YYYYMMDD


The start of the period. The boundary is inclusive.

ShortStarting time with inclusive boundary。[應填入門診日期 OPD Date]
Comments

If the low element is missing, the meaning is that the low boundary is not known.

Control10..1
This element is affected by the following invariants: per-1
TypedateTime
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()))
38. Encounter.reasonCode
Definition

就醫發生的原因,以代碼表示。對於住院,這可用於住院診斷代碼。


Reason the encounter takes place, expressed as a code. For admissions, this can be used for a coded admission diagnosis.

Short就醫發生的編碼原因Coded reason the encounter takes place
Comments

對於需要知道哪個是主要診斷的系統來說,這些將用標準擴充primaryDiagnosis(這是一個序列值而不是一個標誌,1=主要診斷)來標記。


For systems that need to know which was the primary diagnosis, these will be marked with the standard extension primaryDiagnosis (which is a sequence value rather than a flag, 1 = primary diagnosis).

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

發生此就醫事件的原因;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。


Reason why the encounter takes place.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Alternate NamesIndication, Admission diagnosis
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
40. Encounter.hospitalization
Definition

關於入院接受健康照護服務的細節


Details about the admission to a healthcare service.

Short關於入院接受健康照護服務的細節Details about the admission to a healthcare service
Comments

就醫可能不僅僅包括住院治療。其他情境像是門診病人、社區診所和老年照護機構等情況也包括在內。在此就醫期間記錄的持續時間含概此住院紀錄的整個範圍。


An Encounter may cover more than just the inpatient stay. Contexts such as outpatients, community clinics, and aged care facilities are also included.

The duration recorded in the period of this encounter covers the entire scope of this hospitalization record.

Control0..1
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
42. Encounter.hospitalization.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())
44. Encounter.hospitalization.dischargeDisposition
Definition

出院後的地點類別或種類


Category or kind of location after discharge.

Short出院後的地點類別或種類Category or kind of location after discharge
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.

Control0..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see DischargeDispositionhttp://hl7.org/fhir/ValueSet/encounter-discharge-disposition
(example to http://hl7.org/fhir/ValueSet/encounter-discharge-disposition)

出院處置;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。


Discharge Disposition.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
46. Encounter.location
Definition

此次就醫期間,病人曾去過的一個或多個地點


List of locations where the patient has been during this encounter.

Short病人曾去過的一個或多個地點List of locations where the patient has been
Comments

透過指定一個型別「種類(kind)」的地點參照,例如「客戶的家」,以及encounter.class =「虛擬(virtual)」。


Virtual encounters can be recorded in the Encounter by specifying a location reference to a location of type "kind" such as "client's home" and an encounter.class = "virtual".

Control0..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. Encounter.location.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())
50. Encounter.location.location
Definition

就醫發生的地點


The location where the encounter takes place.

Short就醫發生的地點Location the encounter takes place
Control1..1
TypeReference(TW Core Location, Location)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
52. Encounter.serviceProvider
Definition

對此次就醫的服務負主要責任的機構。這可能與病人紀錄中的機構相同,但也可能不同,例如:如果執行服務的人員來自外部機構(可單獨計費)的外部諮詢。請參考Bundle範例顯示結腸鏡檢查就醫縮略集。


The organization that is primarily responsible for this Encounter's services. This MAY be the same as the organization on the Patient record, however it could be different, such as if the actor performing the services was from an external organization (which may be billed seperately) for an external consultation. Refer to the example bundle showing an abbreviated set of Encounters for a colonoscopy.

Short負責這次就醫的機構The organization (facility) responsible for this encounter
Control0..1
TypeReference(TW Core Organization, Organization)
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. Encounter
Definition

病人和健康照護服務提供者之間的互動,目的是提供健康照護服務或評估病人的健康狀況。

Short提供病人服務的一種互動
Control0..*
Is Modifierfalse
Summaryfalse
Alternate NamesVisit
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. Encounter.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Encounter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,此resource沒有id,它的id在resource被創建後由伺器分配/指定。

Control0..1
Typeid
Is Modifierfalse
Summarytrue
4. Encounter.meta
Definition

關於resource的metadata。這是由基礎建設維護的內容。內容的更改可能並不總是與resource的版本更改相關聯。

Short此Encounter 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. Encounter.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。通常這是對IG所定義之特殊規則及其他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交易夥伴所理解。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IG的參照,此IG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. Encounter.language
Definition

編寫此resource的語言

Short用以表述Encounter 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資料項目(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
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. Encounter.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定義有哪些內容應該在敘述中表示,以確保臨床安全。

ShortEncounter 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。有時resource可能只有文字表述,很少或沒有額外的結構化資料(只要滿足所有minOccurs=1的資料項目)。這可能出現在舊系統的資料,當資訊以 「文字表述區塊(text blob) 」的形式被取得,或者文字表述是原始輸入或說明,而編碼資訊稍後再添加。

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. Encounter.contained
Definition

這些resource內嵌(contains)的resource不會另外存於任何FHIR伺服器,意即它們無法在任何FHIR伺服器中被找到,也無法有自己獨立的資料異動/交易(transaction)範圍。

Short內嵌的(contained)、行內的Resources
Comments

當內容可以從任何FHIR伺服器找到時,不應該以內嵌(contained)resource的方式呈現,因為一旦失去識別,再次恢復它是非常困難的(並且取決於情境)。內嵌(contained)的resource可在它們的meta資料項目中表述profiles和tag,但不應該有安全標號(security labels)。

Control0..*
TypeResource
Is Modifierfalse
Summaryfalse
Alternate Namesinline resources, anonymous resources, contained resources
14. Encounter.extension
Definition

可用於表示不屬於此resource基本定義的額外資訊。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,必須(SHALL) 滿足一系列要求。

Short擴充的資料項目
Comments

任何應用程式、專案或標準使用擴充時,都不應該帶有任何負面的聯想。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. Encounter.modifierExtension
Definition

可以用來表示不屬於此resource的基本定義的額外資訊,並修改包含它所內嵌(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的資訊。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。雖然任何實作者都可以定義一個擴充,但在定義擴充時 必須(SHALL) 滿足一組要求。處理resource的應用程式需要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

任何應用程式、專案或標準使用擴充時,都不應該帶有任何負面的聯想。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允許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。這樣做有助於促進可互操作性,因為無需禁止實作者使用擴充,想要瞭解更多資訊,請參見[修飾用的資料項目擴充之定義](http://hl7.org/fhir/R4/extensibility.html#modifierExtension)。

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. Encounter.identifier
Definition

此就醫事件的識別碼

Short此就醫事件的識別碼
NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Is Modifierfalse
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. Encounter.identifier.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
22. Encounter.identifier.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())
SlicingThis element introduces a set of slices on Encounter.identifier.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ url
  • 24. Encounter.identifier.use
    Definition

    這個唯一識別碼(identifier)的用途

    Shortusual | official | temp | secondary | old (如果知道)
    Comments

    應用程式可以假定一個識別碼是永久的,除非它明確說它是暫時的。

    Control0..1
    BindingThe codes SHALL be taken from IdentifierUse
    (required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1)

    如果知道,請說明此識別碼的用途;應填入所綁定值集中的其中一個代碼。

    Typecode
    Is Modifiertrue because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summarytrue
    Requirements

    允許從一組識別碼中為特定的使用情境選擇適當的識別碼

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

    識別碼的代碼型別,用於決定特定目的適用的識別碼。

    Short識別碼(identifier)的型別說明
    Comments

    這個資料項目只涉及識別碼的一般類別。它 必須沒有(SHALL NOT) 被用於與Identifier.system 1..1對應的代碼。一些識別碼可能由於常見的用法而屬於多個類別。在系統是已知的情況下,型別是不必要的,因為型別總是系統定義的一部分。然而,系統經常需要處理系統不為人知的識別碼。型別和系統之間不是1:1的關係,因為許多不同的系統有相同的型別。

    Control0..1
    This element is affected by the following invariants: ele-1
    BindingUnless not suitable, these codes SHALL be taken from Identifier Type Codes
    (extensible to http://hl7.org/fhir/ValueSet/identifier-type)

    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

    允許使用者在不知道識別碼系統的情況下利用識別碼

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    28. Encounter.identifier.system
    Definition

    建立值的命名空間-即一個描述一組值的唯一URL

    Short識別碼(identifier)的命名空間(namespace)
    Comments

    Identifier.system總是區分大小寫

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

    有許多識別碼的集合。為了進行兩個識別碼的對應,我們需要知道我們處理的是哪一組。系統指明了一個特定的唯一識別碼集。

    Example<br/><b>General</b>:http://www.acme.com/identifiers/patient
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    30. Encounter.identifier.value
    Definition

    識別碼中通常與使用者有關的部分,在系統情境內是唯一的。 [原就醫識別碼]為醫療院所開立處方時之就醫識別碼 [就醫識別碼]為本次調劑處方所產製之就醫識別碼

    Short唯一值。[應填入原就醫識別碼/就醫識別碼/健保卡就醫序號]
    Comments

    如果此值是一個完整的URI,那麼此系統 必須(SHALL) 是urn:ietf:rfc:3986。此值的主要目的是為了可運算的對應。因此,為了比較的目的,它可能會被正規化(例如:去除不重要的空白、破折號等)。一個為人顯示的格式化的值可以使用[Rendered Value](http://hl7.org/fhir/R4/extension-rendered-value.html)擴充來傳達。除非對Identifier.system的了解使處理者確信不區分大小寫的處理是安全的,否則Identifier.value應被視為區分大小寫。

    Control1..1
    Typestring
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Example<br/><b>General</b>:123456
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    32. Encounter.identifier.period
    Definition

    識別碼有效/曾經有效使用的時段或期間

    Short此就醫事件識別碼(identifier)的使用效期
    Control0..1
    TypePeriod
    Is Modifierfalse
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    34. Encounter.identifier.assigner
    Definition

    簽發/管理識別碼的機構

    Short簽發identifier的機構(可以只是文字表述)
    Comments

    Identifier.assigner可以省略.reference資料項目,只包含一個.display資料項目,反映指定機構的名稱或其他文字表述資訊。

    Control0..1
    TypeReference(TW Core Organization)
    Is Modifierfalse
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    36. Encounter.status
    Definition

    planned | arrived | triaged | in-progress | onleave | finished | cancelled +.

    Shortplanned | arrived | triaged | in-progress | onleave | finished | cancelled +
    Comments

    請注意,內部業務規則將決定於狀態(也包括類別)間可能發生的適當轉換。

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

    就醫現況的代碼;應填入所綁定值集中的其中一個代碼

    Typecode
    Is Modifiertrue because This element is labeled 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
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    38. Encounter.statusHistory
    Definition

    Encounter resource包含狀態歷史,因而不需閱讀resource的歷史版本,甚至不需讓伺服器儲存這些版本。

    Short過去的就醫狀態清單
    Comments

    總是可在resource的目前版本找到目前狀態,而不是在狀態歷史中找到。

    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    40. Encounter.statusHistory.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
    42. Encounter.statusHistory.extension
    Definition

    可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

    Short擴充的資料項目
    Comments

    無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

    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())
    44. Encounter.statusHistory.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())
    46. Encounter.statusHistory.status
    Definition

    planned | arrived | triaged | in-progress | onleave | finished | cancelled +

    Shortplanned | arrived | triaged | in-progress | onleave | finished | cancelled +
    Control1..1
    BindingThe codes SHALL be taken from EncounterStatus
    (required to http://hl7.org/fhir/ValueSet/encounter-status|4.0.1)

    就醫現狀的代碼;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()))
    48. Encounter.statusHistory.period
    Definition

    該事件處於特定狀態的時間

    Short該事件處於特定狀態的時間
    Control1..1
    TypePeriod
    Is Modifierfalse
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    50. Encounter.class
    Definition

    病人就醫分類的概念,例如:門診病人、住院病人、急診病人、居家照護或其他因地方不同而產生的概念。

    Short病人就醫的分類。[應填入案件分類]
    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
    BindingUnless not suitable, these codes SHALL be taken from ActEncounterCode
    (extensible to http://terminology.hl7.org/ValueSet/v3-ActEncounterCode)

    就醫的分類;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。

    TypeCoding(TW Coding)
    Is Modifierfalse
    Must Supporttrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    52. Encounter.classHistory
    Definition

    可透過類別歷史而不需要透過resource歷史紀錄來追蹤就醫的轉變,這將用於一個案例,即住院急診,然後轉住院的情況。這樣做而不重新啟動一個新的就醫,可以確保任何實驗室/診斷結果可以更容易地跟隨病人,不需要重新處理,也不會在從急診到住院的出院過程中丟失或取消。

    Short過去就醫類別的列表
    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    54. Encounter.classHistory.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
    56. Encounter.classHistory.extension
    Definition

    可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

    Short擴充的資料項目
    Comments

    無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

    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())
    58. Encounter.classHistory.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())
    60. Encounter.classHistory.class
    Definition

    inpatient | outpatient | ambulatory | emergency +. 住院病人 | 門診病人 | 非臥床(可行走)病人醫療服務 | 急診 +

    Shortinpatient | outpatient | ambulatory | emergency +
    Control1..1
    BindingUnless not suitable, these codes SHALL be taken from ActEncounterCode
    (extensible to http://terminology.hl7.org/ValueSet/v3-ActEncounterCode)

    就醫類別;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。

    TypeCoding
    Is Modifierfalse
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    62. Encounter.classHistory.period
    Definition

    此就醫事件處於特定類別的時間

    Short此就醫事件處於特定類別的時間
    Control1..1
    TypePeriod
    Is Modifierfalse
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    64. Encounter.type
    Definition

    就醫的特定型別(如電子郵件諮詢、手術日間照護、專業護理、復健)。 [歸屬]之填入內容建議為計畫案之開立處方,如:藥事照護計畫、戒菸門診、COVID-19…等特殊案件代碼

    Short就醫的特定型別。[應填入歸屬]
    Comments

    由於有許多方法可以對就醫進行進一步的分類,所以這個資料項目的基數是0...* ,意即可不填寫或填寫數筆。

    Control0..*
    This element is affected by the following invariants: ele-1
    BindingFor example codes, see EncounterType
    (example to http://hl7.org/fhir/ValueSet/encounter-type)

    就醫的型別;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()))
    66. Encounter.serviceType
    Definition

    對所提供的服務進行廣泛的分類(如心臟科)

    Short服務的特定型別。[應填入科別 Department]
    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 SNOMED CT + 臺灣健保署 + 衛福部統計處診療科別值集
    (extensible to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/health-department-sct-tw)

    對提供的服務進行廣泛分類;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
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    68. Encounter.priority
    Definition

    表明就醫的急迫性

    Short表明就醫的急迫性
    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.

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

    表明就醫的迫切性;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()))
    70. Encounter.subject
    Definition

    在場就醫的病人或實體集合(Group)

    Short在場就醫的病人或實體集合(Group)
    Comments

    雖然就醫總是關於病人,但在所有的使用情境中,病人實際上可能並不為人所知及可能有一群病人是匿名的(例如:匿名酗酒者的團體治療中—就醫紀錄是以人數/工作人員數計費,而具體病人的情境並不重要);或者在獸醫照護中,一群羊接受治療(動物沒有被單獨追蹤)。

    Control1..1
    TypeReference(Group, 調劑單張-病人基本資料)
    Is Modifierfalse
    Must Supporttrue
    Must Support TypesNo must-support rules about the choice of types/profiles
    Summarytrue
    Alternate Namespatient
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    72. Encounter.episodeOfCare
    Definition

    當某一特定就醫應被歸類為某一特定照護事件的一部分時,應使用這一個資料項目。這種關聯可方便地將相關的就醫分類,以達到特定的目的,如政府報告、問題追蹤、透過共同的問題進行關聯,關聯通常會在照護事件之後記錄在就醫紀錄上,並在紀錄上分類;而不是將另一個就醫(照護事件可能橫跨多年)附件到照護事件紀錄。

    Short此次就醫應記錄的照護事件
    Control0..*
    TypeReference(EpisodeOfCare)
    Is Modifierfalse
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    74. Encounter.basedOn
    Definition

    此就醫事件所要滿足的請求(例如:轉診或手術請求)

    Short開始此次就醫的服務請求(ServiceRequest)
    Control0..*
    TypeReference(ServiceRequest)
    Is Modifierfalse
    Summaryfalse
    Alternate NamesincomingReferral
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    76. Encounter.participant
    Definition

    負責提供健康照護服務的人員名單

    Short參與就醫的健康照護服務提供者之名單
    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    78. Encounter.participant.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
    80. Encounter.participant.extension
    Definition

    可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

    Short擴充的資料項目
    Comments

    無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

    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())
    82. Encounter.participant.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())
    84. Encounter.participant.type
    Definition

    參與者在病人就醫事件中的角色

    Short參與者在病人就醫事件中的角色
    Comments

    參與者的型別表明個人如何參與病人的就醫事件。它包括非執業醫師的參與者,而對於執業醫師來說,這是為了描述在這次就醫中的活動型別(例如:住院醫生、主治醫生、翻譯者、諮詢醫生)。這與執業醫師的角色不同,執業醫師是功能性的角色,衍生自來僱用、教育、執照等。

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

    參與者在病人就醫事件中的角色;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
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    86. Encounter.participant.period
    Definition

    指定的參與者參與病人就醫的時段。這些時段可以是重疊的,也可以是整個就醫的時段的子集。

    Short參與者在病人就醫期間參與的時段
    Control0..1
    TypePeriod
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    88. Encounter.participant.individual
    Definition

    除病人外,參與病人就醫事件的人。

    Short除病人外,參與病人就醫事件的人。
    Control0..1
    TypeReference(TW Core Practitioner, TW Core PractitionerRole, RelatedPerson)
    Is Modifierfalse
    Must Supporttrue
    Must Support TypesNo must-support rules about the choice of types/profiles
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    90. Encounter.appointment
    Definition

    這次就醫的預約紀錄

    Short這次就醫的預約紀錄
    Control0..*
    TypeReference(Appointment)
    Is Modifierfalse
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    92. Encounter.period
    Definition

    就醫的開始和結束時間

    Short就醫的開始和結束時間
    Comments

    如果(尚)不知道,可以省略「期間」裡的結束日期時間。

    Control1..1
    TypePeriod
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    94. Encounter.period.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    96. Encounter.period.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. 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.

    ShortAdditional content defined by implementations
    Comments

    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 Modifierfalse
    Summaryfalse
    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())
    SlicingThis element introduces a set of slices on Encounter.period.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • value @ url
    • 98. Encounter.period.start
      Definition

      The start of the period. The boundary is inclusive. 等同開立處方日期 格式為西元YYYYMMDD

      ShortStarting time with inclusive boundary。[應填入門診日期 OPD Date]
      Comments

      If the low element is missing, the meaning is that the low boundary is not known.

      Control1..1
      This element is affected by the following invariants: per-1
      TypedateTime
      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()))
      100. Encounter.period.end
      Definition

      The end of the period. If the end of the period is missing, it means no end was known or planned at the time the instance was created. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time.

      ShortEnd time with inclusive boundary, if not ongoing
      Comments

      The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.

      Control0..1
      This element is affected by the following invariants: per-1
      TypedateTime
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summarytrue
      Meaning if MissingIf the end of the period is missing, it means that the period is ongoing
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      102. Encounter.length
      Definition

      就醫持續的時間,這不包括請假缺席的時間。

      Short就醫持續的時間(扣除缺席時間)
      Comments

      由於請假,可能與就醫的開始和結束時間(Encounter.period)不同。

      Control0..1
      TypeDuration
      Is Modifierfalse
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      104. Encounter.reasonCode
      Definition

      就醫發生的原因,以代碼表示。對於住院,這可用於住院診斷代碼。

      Short就醫發生的編碼原因
      Comments

      對於需要知道哪個是主要診斷的系統來說,這些將用標準擴充primaryDiagnosis(這是一個序列值而不是一個標誌,1=主要診斷)來標記。

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

      發生此就醫事件的原因;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
      Must Supporttrue
      Alternate NamesIndication, Admission diagnosis
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      106. Encounter.reasonReference
      Definition

      就醫發生的原因,以代碼表示。對於住院,這可用於住院診斷代碼。

      Short就醫發生的原因(參照)
      Comments

      對於需要知道哪個是主要診斷的系統來說,這些將用標準擴充primaryDiagnosis(這是一個序列值而不是一個標誌,1=主要診斷)來標記。

      Control0..*
      TypeReference(TW Core Condition, TW Core Procedure, TW Core Observation Laboratory Result, ImmunizationRecommendation)
      Is Modifierfalse
      Summarytrue
      Alternate NamesIndication, Admission diagnosis
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      108. Encounter.diagnosis
      Definition

      與此就醫相關的診斷清單

      Short與此就醫相關的診斷清單
      Control0..*
      TypeBackboneElement
      Is Modifierfalse
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      110. Encounter.diagnosis.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
      112. Encounter.diagnosis.extension
      Definition

      可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

      Short擴充的資料項目
      Comments

      無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

      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())
      114. Encounter.diagnosis.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())
      116. Encounter.diagnosis.condition
      Definition

      就醫的原因,使用其他resource的資訊以具體說明。對於住院,這就是住院診斷。指示通常是一個病情、問題或診斷(Condition)(在evidence.detail中參照其他resource),或一個處置(Procedure)。

      Short與就醫事件相關的診斷或處置
      Comments

      對於需要知道哪個是主要診斷的系統來說,這些將用標準擴充primaryDiagnosis(這是一個序列值而不是一個標誌,1=主要診斷)來標記。

      Control1..1
      TypeReference(TW Core Condition, TW Core Procedure)
      Is Modifierfalse
      Summarytrue
      Alternate NamesAdmission diagnosis, discharge diagnosis, indication
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      118. Encounter.diagnosis.use
      Definition

      此診斷在病人就醫事件中的作用(例如:住院、收費、出院...)。

      Short此診斷在病人就醫事件中的作用(例如:住院、收費、出院...)。
      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.

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

      此情況所代表的診斷型別;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
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      120. Encounter.diagnosis.rank
      Definition

      診斷的排序(針對每個角色型別)

      Short診斷的排序(針對每個角色型別)
      Control0..1
      TypepositiveInt
      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()))
      122. Encounter.account
      Definition

      可用於為此病人就醫事件計費的一組帳戶

      Short可用於為此病人就醫事件計費的一組帳戶
      Comments

      計費系統可依據內部業務規則,選擇將與就醫(Encounter)相關的應計費項目分配給不同的參照帳戶。

      Control0..*
      TypeReference(Account)
      Is Modifierfalse
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      124. Encounter.hospitalization
      Definition

      關於入院接受健康照護服務的細節

      Short關於入院接受健康照護服務的細節
      Comments

      就醫可能不僅僅包括住院治療。其他情境像是門診病人、社區診所和老年照護機構等情況也包括在內。在此就醫期間記錄的持續時間含概此住院紀錄的整個範圍。

      Control0..1
      TypeBackboneElement
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      126. Encounter.hospitalization.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
      128. Encounter.hospitalization.extension
      Definition

      可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

      Short擴充的資料項目
      Comments

      無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

      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())
      130. Encounter.hospitalization.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())
      132. Encounter.hospitalization.preAdmissionIdentifier
      Definition

      住院前識別碼

      Short住院前識別碼
      Control0..1
      TypeIdentifier
      Is Modifierfalse
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      134. Encounter.hospitalization.origin
      Definition

      病人住院前來自的地點/機構

      Short病人住院前來自的地點/機構
      Control0..1
      TypeReference(TW Core Organization, TW Core Location)
      Is Modifierfalse
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      136. Encounter.hospitalization.admitSource
      Definition

      病人從哪裡住院(醫生轉介、轉院)?

      Short病人從哪裡住院(醫生轉介、轉院)?
      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.

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

      病人從哪裡住院;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
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      138. Encounter.hospitalization.reAdmission
      Definition

      此次住院是否為再入院,如果知道的話,請說明原因。

      Short已發生的醫院再入院型別(如果有的話)。如果該值不存在,則不被認定為再入院。
      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.

      Control0..1
      This element is affected by the following invariants: ele-1
      BindingFor example codes, see hl7VS-re-admissionIndicator
      (example to http://terminology.hl7.org/ValueSet/v2-0092)

      這次住院就醫的再入院原因;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()))
      140. Encounter.hospitalization.dietPreference
      Definition

      病人報告的飲食偏好

      Short病人報告的飲食偏好
      Comments

      例如:一個病人可能同時要求無乳製品和無堅果的飲食偏好(不相互排斥)。

      Control0..*
      This element is affected by the following invariants: ele-1
      BindingFor example codes, see Diet
      (example to http://hl7.org/fhir/ValueSet/encounter-diet)

      醫療、文化或道德方面的食物偏好,以幫助滿足飲食要求;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
      Requirements

      用於追蹤病人的飲食限制和/或偏好。如果要完整描述病人在住院期間的營養需求,應該使用與Encounter連結的nutritionOrder resource。

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      142. Encounter.hospitalization.specialCourtesy
      Definition

      特別禮遇(貴賓、董事會成員)

      Short特別禮遇(貴賓、董事會成員)
      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.

      Control0..*
      This element is affected by the following invariants: ele-1
      BindingThe codes SHOULD be taken from SpecialCourtesy
      (preferred to http://hl7.org/fhir/ValueSet/encounter-special-courtesy)

      特別禮遇;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
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      144. Encounter.hospitalization.specialArrangement
      Definition

      對此次住院就醫提出的任何特殊要求,如提供特定設備或其他東西。

      Short輪椅、翻譯人員、擔架等。
      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.

      Control0..*
      This element is affected by the following invariants: ele-1
      BindingThe codes SHOULD be taken from SpecialArrangements
      (preferred to http://hl7.org/fhir/ValueSet/encounter-special-arrangements)

      特殊安排;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
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      146. Encounter.hospitalization.destination
      Definition

      病人出院地點/機構

      Short病人出院地點/機構
      Control0..1
      TypeReference(TW Core Location, TW Core Organization)
      Is Modifierfalse
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      148. Encounter.hospitalization.dischargeDisposition
      Definition

      出院後的地點類別或種類

      Short出院後的地點類別或種類
      Comments

      Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

      Control0..1
      This element is affected by the following invariants: ele-1
      BindingFor example codes, see DischargeDisposition
      (example to http://hl7.org/fhir/ValueSet/encounter-discharge-disposition)

      出院處置;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
      Must Supporttrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      150. Encounter.location
      Definition

      此次就醫期間,病人曾去過的一個或多個地點

      Short病人曾去過的一個或多個地點
      Comments

      透過指定一個型別「種類(kind)」的地點參照,例如「客戶的家」,以及encounter.class =「虛擬(virtual)」。

      Control0..*
      TypeBackboneElement
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      152. Encounter.location.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
      154. Encounter.location.extension
      Definition

      可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

      Short擴充的資料項目
      Comments

      無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

      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())
      156. Encounter.location.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())
      158. Encounter.location.location
      Definition

      就醫發生的地點

      Short就醫發生的地點
      Control1..1
      TypeReference(TW Core Location)
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      160. Encounter.location.status
      Definition

      參與者在指定期間於特定地點的狀態。如果參與者已不在此地點,那麼其期間將有一個結束日期/時間。

      Shortplanned | active | reserved | completed
      Comments

      當病人不再在某一地點活動時,則要輸入期間結束日期,狀態可改為完成。

      Control0..1
      BindingThe codes SHALL be taken from EncounterLocationStatus
      (required to http://hl7.org/fhir/ValueSet/encounter-location-status|4.0.1)

      就醫地點的狀態;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()))
      162. Encounter.location.physicalType
      Definition

      這將被用來指定所需的地點層級(床位/病房/房間/等),以簡化訊息傳遞或查詢。

      Short地點的實體型別(通常是地點的層級—床位、房間、病房等)。
      Comments

      此資訊是從Location resource中反正規化(de-normalized),以較易理解Encounter resource及支持訊息傳遞或查詢的處理。地點的層級結構中可能有許多層級,這可能只挑選特定使用情境所需的特定層級。

      Control0..1
      This element is affected by the following invariants: ele-1
      BindingFor example codes, see LocationType
      (example to http://hl7.org/fhir/ValueSet/location-physical-type)

      地點的實體型別;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()))
      164. Encounter.location.period
      Definition

      病人出現在此地點的時段

      Short病人出現在此地點的時段
      Control0..1
      TypePeriod
      Is Modifierfalse
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      166. Encounter.serviceProvider
      Definition

      對此次就醫的服務負主要責任的機構。這可能與病人紀錄中的機構相同,但也可能不同,例如:如果執行服務的人員來自外部機構(可單獨計費)的外部諮詢。請參考Bundle範例顯示結腸鏡檢查就醫縮略集。

      Short負責這次就醫的機構
      Control0..1
      TypeReference(TW Core Organization)
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      168. Encounter.partOf
      Definition

      此就醫是哪次就醫的一部分(行政上或時間上)

      Short此就醫是哪次就醫的一部份?
      Comments

      這也用於將小孩的就醫與母親的就醫作關聯。 詳情請參考Patient resource中的Notes小節。

      Control0..1
      TypeReference(TW Core Encounter)
      Is Modifierfalse
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))