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
| Draft as of 2023-10-11 |
JSON representation of the IMAGE logical model.
{
"resourceType" : "StructureDefinition",
"id" : "IMAGE",
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Placeholder</div>"
},
"url" : "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/IMAGE",
"version" : "0.1.0",
"name" : "IMAGE",
"title" : "醫學影像報告邏輯模型",
"status" : "draft",
"date" : "2023-10-11T16:18:20+08:00",
"publisher" : "衛生福利部",
"contact" : [
{
"telecom" : [
{
"system" : "url",
"value" : "https://www.mohw.gov.tw/mp-1.html"
}
]
}
],
"description" : "醫學影像報告邏輯模型，讀者可藉此資料模型快速瞭解醫學影像報告的內容，實作者亦可透過此資料模型上方Mappings功能頁籤來瞭解各資料項目應透過哪些Lung Profiles或Resources的資料項目進行實作。",
"fhirVersion" : "4.0.1",
"mapping" : [
{
"identity" : "rim",
"uri" : "http://hl7.org/v3",
"name" : "RIM Mapping"
},
{
"identity" : "MedicalImagingAndReport",
"uri" : "hl7.org/fhir/r4",
"name" : "Medical Imaging And Report to FHIR"
}
],
"kind" : "logical",
"abstract" : false,
"type" : "https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/IMAGE",
"baseDefinition" : "http://hl7.org/fhir/StructureDefinition/Element",
"derivation" : "specialization",
"snapshot" : {
"element" : [
{
"id" : "IMAGE",
"path" : "IMAGE",
"short" : "此邏輯模型適用於醫學影像報告",
"definition" : "Medical Imaging And Report",
"min" : 0,
"max" : "*",
"base" : {
"path" : "Element",
"min" : 0,
"max" : "*"
},
"condition" : [
"ele-1"
],
"constraint" : [
{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}
],
"isModifier" : false,
"mapping" : [
{
"identity" : "rim",
"map" : "n/a"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "Patient"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "Organization"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "Practitioner"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "Encounter"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "Condition"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "ImagingStudy"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "Observation"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "DiagnosticReport"
}
]
},
{
"id" : "IMAGE.id",
"path" : "IMAGE.id",
"representation" : [
"xmlAttr"
],
"short" : "Unique id for inter-element referencing",
"definition" : "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Element.id",
"min" : 0,
"max" : "1"
},
"type" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl" : "string"
}
],
"code" : "http://hl7.org/fhirpath/System.String"
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "rim",
"map" : "n/a"
}
]
},
{
"id" : "IMAGE.extension",
"path" : "IMAGE.extension",
"slicing" : {
"discriminator" : [
{
"type" : "value",
"path" : "url"
}
],
"description" : "Extensions are always sliced by (at least) url",
"rules" : "open"
},
"short" : "Additional content defined by implementations",
"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.",
"comment" : "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.",
"alias" : [
"extensions",
"user content"
],
"min" : 0,
"max" : "*",
"base" : {
"path" : "Element.extension",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Extension"
}
],
"constraint" : [
{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
},
{
"key" : "ext-1",
"severity" : "error",
"human" : "Must have either extensions or value[x], not both",
"expression" : "extension.exists() != value.exists()",
"xpath" : "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source" : "http://hl7.org/fhir/StructureDefinition/Extension"
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "rim",
"map" : "n/a"
}
]
},
{
"id" : "IMAGE.hospitaltype",
"path" : "IMAGE.hospitaltype",
"short" : "醫院別",
"definition" : "醫院別",
"min" : 1,
"max" : "1",
"base" : {
"path" : "IMAGE.hospitaltype",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "Base"
}
]
},
{
"id" : "IMAGE.hospitaltype.id",
"path" : "IMAGE.hospitaltype.id",
"short" : "醫事機構代碼，院所代碼需與健保申報相同",
"definition" : "醫事機構代碼，院所代碼需與健保申報相同",
"min" : 1,
"max" : "1",
"base" : {
"path" : "IMAGE.hospitaltype.id",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "Identifier"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "醫事機構代碼:Organization.identifier.value 使用 Organization.identifier.type 識別類型"
}
]
},
{
"id" : "IMAGE.hospitaltype.name",
"path" : "IMAGE.hospitaltype.name",
"short" : "醫事機構名稱，院所名稱需與健保申報相同",
"definition" : "醫事機構名稱，院所名稱需與健保申報相同",
"min" : 1,
"max" : "1",
"base" : {
"path" : "IMAGE.hospitaltype.name",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "string"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "院所名稱:Organization.name"
}
]
},
{
"id" : "IMAGE.order",
"path" : "IMAGE.order",
"short" : "檢查項目",
"definition" : "檢查項目",
"min" : 1,
"max" : "1",
"base" : {
"path" : "IMAGE.order",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "Base"
}
]
},
{
"id" : "IMAGE.order.code",
"path" : "IMAGE.order.code",
"short" : "醫令代碼，檢查健保醫令代碼，需與健保申報相同。",
"definition" : "醫令代碼，檢查健保醫令代碼，需與健保申報相同。",
"min" : 1,
"max" : "1",
"base" : {
"path" : "IMAGE.order.code",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "CodeableConcept"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "檢查健保醫令代碼:ImagingStudy.procedureCode.coding.code"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "檢查健保醫令代碼:Observation.code.coding.code"
}
]
},
{
"id" : "IMAGE.order.description",
"path" : "IMAGE.order.description",
"short" : "醫令名稱，檢查健保醫令名稱，需與健保申報相同。",
"definition" : "醫令名稱，檢查健保醫令名稱，需與健保申報相同。",
"min" : 1,
"max" : "1",
"base" : {
"path" : "IMAGE.order.description",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "string"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "醫令名稱:ImagingStudy.procedureCode.coding.display"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "醫令名稱:Observation.code.coding.display"
}
]
},
{
"id" : "IMAGE.examinationStatus",
"path" : "IMAGE.examinationStatus",
"short" : "檢查部位",
"definition" : "檢查部位",
"min" : 1,
"max" : "1",
"base" : {
"path" : "IMAGE.examinationStatus",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "Base"
}
]
},
{
"id" : "IMAGE.examinationStatus.physicalExamination",
"path" : "IMAGE.examinationStatus.physicalExamination",
"short" : "檢查部位，檢查部位，需與健保申報相同。",
"definition" : "檢查部位，檢查部位，需與健保申報相同。",
"min" : 1,
"max" : "*",
"base" : {
"path" : "IMAGE.examinationStatus.physicalExamination",
"min" : 1,
"max" : "*"
},
"type" : [
{
"code" : "Coding"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "檢查部位:ImagingStudy.series.bodySite"
}
]
},
{
"id" : "IMAGE.examinationStatus.description",
"path" : "IMAGE.examinationStatus.description",
"short" : "檢查部位詳細說明、拍攝方向與角度等",
"definition" : "檢查部位詳細說明、拍攝方向與角度等",
"min" : 0,
"max" : "1",
"base" : {
"path" : "IMAGE.examinationStatus.description",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "string"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "檢查部位說明:ImagingStudy.series.description"
}
]
},
{
"id" : "IMAGE.numberOfInstances",
"path" : "IMAGE.numberOfInstances",
"short" : "檢查張數",
"definition" : "檢查張數",
"min" : 1,
"max" : "*",
"base" : {
"path" : "IMAGE.numberOfInstances",
"min" : 1,
"max" : "*"
},
"type" : [
{
"code" : "unsignedInt"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "醫療影像張數:ImagingStudy.numberOfInstances"
}
]
},
{
"id" : "IMAGE.accessionNo",
"path" : "IMAGE.accessionNo",
"short" : "檢查單號，須與影像資料串連，每筆檢查必須有獨立不重複的單號。",
"definition" : "檢查單號，須與影像資料串連，每筆檢查必須有獨立不重複的單號。",
"min" : 1,
"max" : "1",
"base" : {
"path" : "IMAGE.accessionNo",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "Identifier"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "檢查單號:ImagingStudy.identifier"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "檢查單號:Observation.identifier"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "檢查單號:DiagnosticReport.identifier"
}
]
},
{
"id" : "IMAGE.patientInformation",
"path" : "IMAGE.patientInformation",
"short" : "病人基本資料",
"definition" : "病人基本資料",
"min" : 1,
"max" : "1",
"base" : {
"path" : "IMAGE.patientInformation",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "Base"
}
]
},
{
"id" : "IMAGE.patientInformation.idNumber",
"path" : "IMAGE.patientInformation.idNumber",
"short" : "身分證號，病人身分證號。",
"definition" : "身分證號，病人身分證號。",
"min" : 1,
"max" : "1",
"base" : {
"path" : "IMAGE.patientInformation.idNumber",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "Identifier"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "身分證:Patient.identifier.value 使用 Patient.identifier.type 識別類型"
}
]
},
{
"id" : "IMAGE.patientInformation.chartNO",
"path" : "IMAGE.patientInformation.chartNO",
"short" : "病歷號碼，院內病歷號碼。",
"definition" : "病歷號碼，院內病歷號碼。",
"min" : 1,
"max" : "1",
"base" : {
"path" : "IMAGE.patientInformation.chartNO",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "Identifier"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "病歷號:Patient.identifier.value 使用 Patient.identifier.type 識別類型"
}
]
},
{
"id" : "IMAGE.patientInformation.name",
"path" : "IMAGE.patientInformation.name",
"short" : "姓名",
"definition" : "姓名",
"min" : 1,
"max" : "1",
"base" : {
"path" : "IMAGE.patientInformation.name",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "string"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "病人性名:Patient.name"
}
]
},
{
"id" : "IMAGE.patientInformation.administrativeSex",
"path" : "IMAGE.patientInformation.administrativeSex",
"short" : "性別",
"definition" : "性別",
"min" : 1,
"max" : "1",
"base" : {
"path" : "IMAGE.patientInformation.administrativeSex",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "code"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "病人性別:Patient.gender"
}
]
},
{
"id" : "IMAGE.patientInformation.birthDate",
"path" : "IMAGE.patientInformation.birthDate",
"short" : "出生日期",
"definition" : "出生日期",
"min" : 1,
"max" : "1",
"base" : {
"path" : "IMAGE.patientInformation.birthDate",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "date"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "病人出生日期:Patient.birthDate"
}
]
},
{
"id" : "IMAGE.medicalOrder",
"path" : "IMAGE.medicalOrder",
"short" : "醫囑時間及醫囑醫師資料",
"definition" : "醫囑時間及醫囑醫師資料",
"min" : 1,
"max" : "1",
"base" : {
"path" : "IMAGE.medicalOrder",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "Base"
}
]
},
{
"id" : "IMAGE.medicalOrder.orderDatetime",
"path" : "IMAGE.medicalOrder.orderDatetime",
"short" : "醫囑時間，醫囑日期（分），格式為西元YYYYMMDDHHMM。",
"definition" : "醫囑時間，醫囑日期（分），格式為西元YYYYMMDDHHMM。",
"min" : 1,
"max" : "1",
"base" : {
"path" : "IMAGE.medicalOrder.orderDatetime",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "Period"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "醫囑時間，醫囑日期（分）:Encounter.period"
}
]
},
{
"id" : "IMAGE.medicalOrder.orderPhysician",
"path" : "IMAGE.medicalOrder.orderPhysician",
"short" : "醫囑醫師姓名",
"definition" : "醫囑醫師姓名",
"min" : 1,
"max" : "1",
"base" : {
"path" : "IMAGE.medicalOrder.orderPhysician",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "Practitioner"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "醫囑醫師姓名:Practitioner.name"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "醫囑醫師:Encounter.participant.individual"
}
]
},
{
"id" : "IMAGE.historyOfPresentIllness",
"path" : "IMAGE.historyOfPresentIllness",
"short" : "病史，病人病史，內容可以包含主訴、適應症等。",
"definition" : "病史，病人病史，內容可以包含主訴、適應症等。",
"min" : 1,
"max" : "*",
"base" : {
"path" : "IMAGE.historyOfPresentIllness",
"min" : 1,
"max" : "*"
},
"type" : [
{
"code" : "CodeableConcept"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "病史，病人病史，內容可以包含主訴、適應症等:Condition.code"
}
]
},
{
"id" : "IMAGE.diagnosisICDcode",
"path" : "IMAGE.diagnosisICDcode",
"short" : "疾病診斷，疾病診斷代碼及文字。",
"definition" : "疾病診斷，疾病診斷代碼及文字。",
"min" : 0,
"max" : "*",
"base" : {
"path" : "IMAGE.diagnosisICDcode",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "CodeableConcept"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "疾病診斷代碼:DiagnosticReport.code"
}
]
},
{
"id" : "IMAGE.examDatetime",
"path" : "IMAGE.examDatetime",
"short" : "實際檢查日期時間(分) ，格式為西元YYYYMMDDHHMM。",
"definition" : "實際檢查日期時間(分) ，格式為西元YYYYMMDDHHMM。",
"min" : 1,
"max" : "1",
"base" : {
"path" : "IMAGE.examDatetime",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "dateTime"
}
]
},
{
"id" : "IMAGE.picture",
"path" : "IMAGE.picture",
"short" : "圖片",
"definition" : "圖片",
"min" : 1,
"max" : "*",
"base" : {
"path" : "IMAGE.picture",
"min" : 1,
"max" : "*"
},
"type" : [
{
"code" : "ImagingStudy"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "圖片:ImagingStudy"
}
]
},
{
"id" : "IMAGE.recordTotal",
"path" : "IMAGE.recordTotal",
"short" : "報告結果，含影像發現、臆斷及註記(如過敏反應、顯影劑種類等)。",
"definition" : "報告結果，含影像發現、臆斷及註記(如過敏反應、顯影劑種類等)。",
"min" : 1,
"max" : "*",
"base" : {
"path" : "IMAGE.recordTotal",
"min" : 1,
"max" : "*"
},
"type" : [
{
"code" : "string"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "報告結果(Finding):Observation.valueString 如果可編碼請使用 Observation.component"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "報告結果(interpretation/impression):DiagnosticReport.conclusion"
}
]
},
{
"id" : "IMAGE.radiologyStudyRecommendation",
"path" : "IMAGE.radiologyStudyRecommendation",
"short" : "醫師總結之建議。",
"definition" : "醫師總結之建議。",
"min" : 0,
"max" : "1",
"base" : {
"path" : "IMAGE.radiologyStudyRecommendation",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "Annotation"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "醫師總結隻建議:Observation.note"
}
]
},
{
"id" : "IMAGE.verificationTime",
"path" : "IMAGE.verificationTime",
"short" : "確認報告時間(分)，格式為西元YYYYMMDDHHMM。",
"definition" : "確認報告時間(分)，格式為西元YYYYMMDDHHMM。",
"min" : 1,
"max" : "1",
"base" : {
"path" : "IMAGE.verificationTime",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "dateTime"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "確認報告時間:Observation.effective[x]"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "確認報告時間:DiagnosticReport.effective[x]"
}
]
},
{
"id" : "IMAGE.verificationPhysician",
"path" : "IMAGE.verificationPhysician",
"short" : "報告醫師姓名",
"definition" : "報告醫師姓名",
"min" : 1,
"max" : "1",
"base" : {
"path" : "IMAGE.verificationPhysician",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "Practitioner"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "報告醫師姓名:Practitioner.name"
}
]
}
]
},
"differential" : {
"element" : [
{
"id" : "IMAGE",
"path" : "IMAGE",
"short" : "此邏輯模型適用於醫學影像報告",
"definition" : "Medical Imaging And Report",
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "Patient"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "Organization"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "Practitioner"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "Encounter"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "Condition"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "ImagingStudy"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "Observation"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "DiagnosticReport"
}
]
},
{
"id" : "IMAGE.hospitaltype",
"path" : "IMAGE.hospitaltype",
"short" : "醫院別",
"definition" : "醫院別",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "Base"
}
]
},
{
"id" : "IMAGE.hospitaltype.id",
"path" : "IMAGE.hospitaltype.id",
"short" : "醫事機構代碼，院所代碼需與健保申報相同",
"definition" : "醫事機構代碼，院所代碼需與健保申報相同",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "Identifier"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "醫事機構代碼:Organization.identifier.value 使用 Organization.identifier.type 識別類型"
}
]
},
{
"id" : "IMAGE.hospitaltype.name",
"path" : "IMAGE.hospitaltype.name",
"short" : "醫事機構名稱，院所名稱需與健保申報相同",
"definition" : "醫事機構名稱，院所名稱需與健保申報相同",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "string"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "院所名稱:Organization.name"
}
]
},
{
"id" : "IMAGE.order",
"path" : "IMAGE.order",
"short" : "檢查項目",
"definition" : "檢查項目",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "Base"
}
]
},
{
"id" : "IMAGE.order.code",
"path" : "IMAGE.order.code",
"short" : "醫令代碼，檢查健保醫令代碼，需與健保申報相同。",
"definition" : "醫令代碼，檢查健保醫令代碼，需與健保申報相同。",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "CodeableConcept"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "檢查健保醫令代碼:ImagingStudy.procedureCode.coding.code"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "檢查健保醫令代碼:Observation.code.coding.code"
}
]
},
{
"id" : "IMAGE.order.description",
"path" : "IMAGE.order.description",
"short" : "醫令名稱，檢查健保醫令名稱，需與健保申報相同。",
"definition" : "醫令名稱，檢查健保醫令名稱，需與健保申報相同。",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "string"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "醫令名稱:ImagingStudy.procedureCode.coding.display"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "醫令名稱:Observation.code.coding.display"
}
]
},
{
"id" : "IMAGE.examinationStatus",
"path" : "IMAGE.examinationStatus",
"short" : "檢查部位",
"definition" : "檢查部位",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "Base"
}
]
},
{
"id" : "IMAGE.examinationStatus.physicalExamination",
"path" : "IMAGE.examinationStatus.physicalExamination",
"short" : "檢查部位，檢查部位，需與健保申報相同。",
"definition" : "檢查部位，檢查部位，需與健保申報相同。",
"min" : 1,
"max" : "*",
"type" : [
{
"code" : "Coding"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "檢查部位:ImagingStudy.series.bodySite"
}
]
},
{
"id" : "IMAGE.examinationStatus.description",
"path" : "IMAGE.examinationStatus.description",
"short" : "檢查部位詳細說明、拍攝方向與角度等",
"definition" : "檢查部位詳細說明、拍攝方向與角度等",
"min" : 0,
"max" : "1",
"type" : [
{
"code" : "string"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "檢查部位說明:ImagingStudy.series.description"
}
]
},
{
"id" : "IMAGE.numberOfInstances",
"path" : "IMAGE.numberOfInstances",
"short" : "檢查張數",
"definition" : "檢查張數",
"min" : 1,
"max" : "*",
"type" : [
{
"code" : "unsignedInt"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "醫療影像張數:ImagingStudy.numberOfInstances"
}
]
},
{
"id" : "IMAGE.accessionNo",
"path" : "IMAGE.accessionNo",
"short" : "檢查單號，須與影像資料串連，每筆檢查必須有獨立不重複的單號。",
"definition" : "檢查單號，須與影像資料串連，每筆檢查必須有獨立不重複的單號。",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "Identifier"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "檢查單號:ImagingStudy.identifier"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "檢查單號:Observation.identifier"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "檢查單號:DiagnosticReport.identifier"
}
]
},
{
"id" : "IMAGE.patientInformation",
"path" : "IMAGE.patientInformation",
"short" : "病人基本資料",
"definition" : "病人基本資料",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "Base"
}
]
},
{
"id" : "IMAGE.patientInformation.idNumber",
"path" : "IMAGE.patientInformation.idNumber",
"short" : "身分證號，病人身分證號。",
"definition" : "身分證號，病人身分證號。",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "Identifier"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "身分證:Patient.identifier.value 使用 Patient.identifier.type 識別類型"
}
]
},
{
"id" : "IMAGE.patientInformation.chartNO",
"path" : "IMAGE.patientInformation.chartNO",
"short" : "病歷號碼，院內病歷號碼。",
"definition" : "病歷號碼，院內病歷號碼。",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "Identifier"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "病歷號:Patient.identifier.value 使用 Patient.identifier.type 識別類型"
}
]
},
{
"id" : "IMAGE.patientInformation.name",
"path" : "IMAGE.patientInformation.name",
"short" : "姓名",
"definition" : "姓名",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "string"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "病人性名:Patient.name"
}
]
},
{
"id" : "IMAGE.patientInformation.administrativeSex",
"path" : "IMAGE.patientInformation.administrativeSex",
"short" : "性別",
"definition" : "性別",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "code"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "病人性別:Patient.gender"
}
]
},
{
"id" : "IMAGE.patientInformation.birthDate",
"path" : "IMAGE.patientInformation.birthDate",
"short" : "出生日期",
"definition" : "出生日期",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "date"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "病人出生日期:Patient.birthDate"
}
]
},
{
"id" : "IMAGE.medicalOrder",
"path" : "IMAGE.medicalOrder",
"short" : "醫囑時間及醫囑醫師資料",
"definition" : "醫囑時間及醫囑醫師資料",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "Base"
}
]
},
{
"id" : "IMAGE.medicalOrder.orderDatetime",
"path" : "IMAGE.medicalOrder.orderDatetime",
"short" : "醫囑時間，醫囑日期（分），格式為西元YYYYMMDDHHMM。",
"definition" : "醫囑時間，醫囑日期（分），格式為西元YYYYMMDDHHMM。",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "Period"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "醫囑時間，醫囑日期（分）:Encounter.period"
}
]
},
{
"id" : "IMAGE.medicalOrder.orderPhysician",
"path" : "IMAGE.medicalOrder.orderPhysician",
"short" : "醫囑醫師姓名",
"definition" : "醫囑醫師姓名",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "Practitioner"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "醫囑醫師姓名:Practitioner.name"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "醫囑醫師:Encounter.participant.individual"
}
]
},
{
"id" : "IMAGE.historyOfPresentIllness",
"path" : "IMAGE.historyOfPresentIllness",
"short" : "病史，病人病史，內容可以包含主訴、適應症等。",
"definition" : "病史，病人病史，內容可以包含主訴、適應症等。",
"min" : 1,
"max" : "*",
"type" : [
{
"code" : "CodeableConcept"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "病史，病人病史，內容可以包含主訴、適應症等:Condition.code"
}
]
},
{
"id" : "IMAGE.diagnosisICDcode",
"path" : "IMAGE.diagnosisICDcode",
"short" : "疾病診斷，疾病診斷代碼及文字。",
"definition" : "疾病診斷，疾病診斷代碼及文字。",
"min" : 0,
"max" : "*",
"type" : [
{
"code" : "CodeableConcept"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "疾病診斷代碼:DiagnosticReport.code"
}
]
},
{
"id" : "IMAGE.examDatetime",
"path" : "IMAGE.examDatetime",
"short" : "實際檢查日期時間(分) ，格式為西元YYYYMMDDHHMM。",
"definition" : "實際檢查日期時間(分) ，格式為西元YYYYMMDDHHMM。",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "dateTime"
}
]
},
{
"id" : "IMAGE.picture",
"path" : "IMAGE.picture",
"short" : "圖片",
"definition" : "圖片",
"min" : 1,
"max" : "*",
"type" : [
{
"code" : "ImagingStudy"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "圖片:ImagingStudy"
}
]
},
{
"id" : "IMAGE.recordTotal",
"path" : "IMAGE.recordTotal",
"short" : "報告結果，含影像發現、臆斷及註記(如過敏反應、顯影劑種類等)。",
"definition" : "報告結果，含影像發現、臆斷及註記(如過敏反應、顯影劑種類等)。",
"min" : 1,
"max" : "*",
"type" : [
{
"code" : "string"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "報告結果(Finding):Observation.valueString 如果可編碼請使用 Observation.component"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "報告結果(interpretation/impression):DiagnosticReport.conclusion"
}
]
},
{
"id" : "IMAGE.radiologyStudyRecommendation",
"path" : "IMAGE.radiologyStudyRecommendation",
"short" : "醫師總結之建議。",
"definition" : "醫師總結之建議。",
"min" : 0,
"max" : "1",
"type" : [
{
"code" : "Annotation"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "醫師總結隻建議:Observation.note"
}
]
},
{
"id" : "IMAGE.verificationTime",
"path" : "IMAGE.verificationTime",
"short" : "確認報告時間(分)，格式為西元YYYYMMDDHHMM。",
"definition" : "確認報告時間(分)，格式為西元YYYYMMDDHHMM。",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "dateTime"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "確認報告時間:Observation.effective[x]"
},
{
"identity" : "MedicalImagingAndReport",
"map" : "確認報告時間:DiagnosticReport.effective[x]"
}
]
},
{
"id" : "IMAGE.verificationPhysician",
"path" : "IMAGE.verificationPhysician",
"short" : "報告醫師姓名",
"definition" : "報告醫師姓名",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "Practitioner"
}
],
"mapping" : [
{
"identity" : "MedicalImagingAndReport",
"map" : "報告醫師姓名:Practitioner.name"
}
]
}
]
}
}