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
Official URL: https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/ImageComposition | Version: 0.1.0 | |||
Draft as of 2024-01-31 | Computable Name: ImageComposition |
此Profile說明本IG如何進一步定義FHIR的Composition Resource以呈現完整影像報告之內容
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from TWCoreComposition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | TWCoreComposition | 醫療影像及報告Composition | |
type | ||||
coding | 1..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Required Pattern: At least the following | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18782-3 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Radiology Study observation (narrative) | |
subject | 1..1 | Reference(醫療影像及報告-病患基本資料) | Composition是關於誰和/或什麼 | |
encounter | 0..1 | Reference(醫療影像及報告-醫囑時間) | Composition的情境 | |
date | 1..1 | dateTime | Composition編輯時間 | |
author | 1..1 | Reference(醫療影像及報告-醫事機構基本資料) | 什麼機構撰寫此醫療影像及報告 | |
title | 1..1 | string | 醫療影像及報告 | |
attester | 0..1 | BackboneElement | 證明Composition的準確性 | |
time | S | 0..1 | dateTime | Composition何時被證明 |
party | S | 1..1 | Reference(醫療影像及報告-醫事機構基本資料) | 誰證明這個Composition |
section | 0..* | BackboneElement | Section的標籤(例如:目錄) | |
code | 1..1 | CodeableConceptTW | 小節分類(建議) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Relevant diagnostic tests/laboratory data Narrative | |
coding | 1..* | CodingTW | 由專門術語系統(terminology system)定義的代碼 | |
text | 0..1 | Narrative | Section的摘要,供人解讀。 | |
Slices for entry | 5..* | Reference(Resource) | 提供一個連結用於參照或查看支持此小節內容的資料 Slice: Unordered, Open by profile:resolve() | |
entry:Practitioner | 1..1 | Reference(醫療影像及報告-醫事人員基本資料) | 支援這個section的資料之參照 | |
entry:Condition | 1..1 | Reference(醫療影像及報告-病史) | 支援這個section的資料之參照 | |
entry:Observation | 1..1 | Reference(醫療影像及報告-影像檢驗報告) | 支援這個section的資料之參照 | |
entry:DiagnosticReport | 1..1 | Reference(DiagnosticReport Image) | 支援這個section的資料之參照 | |
entry:ImagingStudy | 1..1 | Reference(醫療影像及報告-醫學影像內容) | 支援這個section的資料之參照 | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | TWCoreComposition | 醫療影像及報告Composition | |
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 |
modifierExtension | ?! | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 |
identifier | SΣ | 0..1 | Identifier | 不分版本的臨床文件架構(Composition)識別碼。 |
status | ?!SΣ | 1..1 | code | registered | partial | preliminary | final | amended | corrected + Binding: CompositionStatus (required): Composition的工作流程/臨床狀態;應填入所綁定值集中的其中一個代碼。 |
type | S | 1..1 | CodeableConceptTW | Composition的種類(如果可能請使用LOINC) Binding: FHIRDocumentTypeCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 |
coding | S | 1..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Required Pattern: At least the following |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18782-3 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Radiology Study observation (narrative) | |
text | SΣ | 0..1 | string | 概念的文字表示法 |
subject | SΣ | 1..1 | Reference(醫療影像及報告-病患基本資料) | Composition是關於誰和/或什麼 |
encounter | Σ | 0..1 | Reference(醫療影像及報告-醫囑時間) | Composition的情境 |
date | SΣ | 1..1 | dateTime | Composition編輯時間 |
author | SΣ | 1..1 | Reference(醫療影像及報告-醫事機構基本資料) | 什麼機構撰寫此醫療影像及報告 |
title | SΣ | 1..1 | string | 醫療影像及報告 |
attester | S | 0..1 | BackboneElement | 證明Composition的準確性 |
modifierExtension | ?!Σ | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 |
mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): 認證者提供的認證類型;應填入所綁定值集中的其中一個代碼。 | |
time | S | 0..1 | dateTime | Composition何時被證明 |
party | S | 1..1 | Reference(醫療影像及報告-醫事機構基本資料) | 誰證明這個Composition |
custodian | SΣ | 0..1 | Reference(TW Core Organization) | 維護Composition的機構 |
section | SC | 0..* | BackboneElement | Section的標籤(例如:目錄) cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 |
code | S | 1..1 | CodeableConceptTW | 小節分類(建議) Binding: DocumentSectionCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Relevant diagnostic tests/laboratory data Narrative | |
coding | S | 1..* | CodingTW | 由專門術語系統(terminology system)定義的代碼 |
text | SΣ | 0..1 | string | 概念的文字表示法 |
text | SC | 0..1 | Narrative | Section的摘要,供人解讀。 |
Slices for entry | SC | 5..* | Reference(Resource) | 提供一個連結用於參照或查看支持此小節內容的資料 Slice: Unordered, Open by profile:resolve() |
entry:Practitioner | SC | 1..1 | Reference(醫療影像及報告-醫事人員基本資料) | 支援這個section的資料之參照 |
entry:Condition | SC | 1..1 | Reference(醫療影像及報告-病史) | 支援這個section的資料之參照 |
entry:Observation | SC | 1..1 | Reference(醫療影像及報告-影像檢驗報告) | 支援這個section的資料之參照 |
entry:DiagnosticReport | SC | 1..1 | Reference(DiagnosticReport Image) | 支援這個section的資料之參照 |
entry:ImagingStudy | SC | 1..1 | Reference(醫療影像及報告-醫學影像內容) | 支援這個section的資料之參照 |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | |
Composition.type | extensible | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | |
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | |
Composition.section.code | extensible | Pattern: LOINC Code 30954-2("Relevant diagnostic tests/laboratory data Narrative")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | 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 | error | Composition | 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 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Composition | 0..* | TWCoreComposition | 醫療影像及報告Composition | |||||
id | Σ | 0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的Composition紀錄,通常又稱為邏輯性ID。 | ||||
meta | Σ | 0..1 | Meta | 此Composition Resource的metadata | ||||
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 | ||||
language | 0..1 | code | 用以表述Composition Resource內容的語言 Binding: CommonLanguages (preferred): 人類語言;鼓勵使用所綁定值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。
Example Value: zh-TW | |||||
text | 0..1 | Narrative | Composition Resource之內容摘要以供人閱讀 | |||||
contained | 0..* | Resource | 內嵌的(contained)、行內的Resources | |||||
extension | 0..* | Extension | 擴充的資料項目 | |||||
modifierExtension | ?! | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 | ||||
identifier | SΣ | 0..1 | Identifier | 不分版本的臨床文件架構(Composition)識別碼。 | ||||
status | ?!SΣ | 1..1 | code | registered | partial | preliminary | final | amended | corrected + Binding: CompositionStatus (required): Composition的工作流程/臨床狀態;應填入所綁定值集中的其中一個代碼。 | ||||
type | S | 1..1 | CodeableConceptTW | Composition的種類(如果可能請使用LOINC) Binding: FHIRDocumentTypeCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 Slice: Unordered, Open by value:url | |||||
coding | S | 1..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18782-3 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Radiology Study observation (narrative) | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | SΣ | 0..1 | string | 概念的文字表示法 | ||||
category | 0..* | CodeableConceptTW | Composition的分類 Binding: DocumentClassValueSet (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | |||||
subject | SΣ | 1..1 | Reference(醫療影像及報告-病患基本資料) | Composition是關於誰和/或什麼 | ||||
encounter | Σ | 0..1 | Reference(醫療影像及報告-醫囑時間) | Composition的情境 | ||||
date | SΣ | 1..1 | dateTime | Composition編輯時間 | ||||
author | SΣ | 1..1 | Reference(醫療影像及報告-醫事機構基本資料) | 什麼機構撰寫此醫療影像及報告 | ||||
title | SΣ | 1..1 | string | 醫療影像及報告 | ||||
confidentiality | Σ | 0..1 | code | 根據特定技術領域的定義 Binding: v3.ConfidentialityClassification (2014-03-26) (required): 應填入所綁定值集中的其中一個代碼。 | ||||
attester | S | 0..1 | BackboneElement | 證明Composition的準確性 | ||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 | |||||
modifierExtension | ?!Σ | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 | ||||
mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): 認證者提供的認證類型;應填入所綁定值集中的其中一個代碼。 | |||||
time | S | 0..1 | dateTime | Composition何時被證明 | ||||
party | S | 1..1 | Reference(醫療影像及報告-醫事機構基本資料) | 誰證明這個Composition | ||||
custodian | SΣ | 0..1 | Reference(TW Core Organization) | 維護Composition的機構 | ||||
relatesTo | 0..* | BackboneElement | 與其他Composition/文件之間的關係 | |||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 | |||||
modifierExtension | ?!Σ | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 | ||||
code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): 檔案之間的關係型別;應填入所綁定值集中的其中一個代碼。 | |||||
target[x] | 1..1 | 此關係的目標文件 | ||||||
targetIdentifier | Identifier | |||||||
targetReference | Reference(Composition) | |||||||
event | Σ | 0..* | BackboneElement | 正在記錄的臨床服務 | ||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 | |||||
modifierExtension | ?!Σ | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 | ||||
code | 0..* | CodeableConceptTW | 此代碼表代表了正在被記錄的主要臨床行為 Binding: v3 Code System ActCode (example): 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。 | |||||
period | Σ | 0..1 | Period | 文件所涵蓋的時間區間 | ||||
detail | Σ | 0..* | Reference(Resource) | 在描述被記錄下來的事件,這些事件可以是以代碼的形式、參考資料的形式,或者兩者都有的形式來呈現。 | ||||
section | SC | 0..* | BackboneElement | Section的標籤(例如:目錄) cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 | |||||
modifierExtension | ?!Σ | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 | ||||
title | 0..1 | string | 小節標籤(例如:目錄ToC) | |||||
code | S | 1..1 | CodeableConceptTW | 小節分類(建議) Binding: DocumentSectionCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Relevant diagnostic tests/laboratory data Narrative | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 Slice: Unordered, Open by value:url | |||||
coding | S | 1..* | CodingTW | 由專門術語系統(terminology system)定義的代碼 | ||||
text | SΣ | 0..1 | string | 概念的文字表示法 | ||||
author | 0..* | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | TW Core Patient | Device | RelatedPerson) | 誰和/或什麼人撰寫了該小節 | |||||
focus | 0..1 | Reference(Resource) | 當小節與composition描述的對象無關時,此小節是關於誰/什麼。 | |||||
text | SC | 0..1 | Narrative | Section的摘要,供人解讀。 | ||||
mode | 0..1 | code | 適用於此小節的處理模式 Binding: ListMode (required): 應填入所綁定值集中的其中一個代碼。 | |||||
orderedBy | 0..1 | CodeableConceptTW | 小節條目的順序 Binding: ListOrderCodes (preferred): 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。 | |||||
Slices for entry | SC | 5..* | Reference(Resource) | 提供一個連結用於參照或查看支持此小節內容的資料 Slice: Unordered, Open by profile:resolve() | ||||
entry:Practitioner | SC | 1..1 | Reference(醫療影像及報告-醫事人員基本資料) | 支援這個section的資料之參照 | ||||
entry:Condition | SC | 1..1 | Reference(醫療影像及報告-病史) | 支援這個section的資料之參照 | ||||
entry:Observation | SC | 1..1 | Reference(醫療影像及報告-影像檢驗報告) | 支援這個section的資料之參照 | ||||
entry:DiagnosticReport | SC | 1..1 | Reference(DiagnosticReport Image) | 支援這個section的資料之參照 | ||||
entry:ImagingStudy | SC | 1..1 | Reference(醫療影像及報告-醫學影像內容) | 支援這個section的資料之參照 | ||||
emptyReason | 0..1 | CodeableConceptTW | 為什麼此小節是空的原因 Binding: ListEmptyReasons (preferred): 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。 | |||||
section | C | 0..* | See section (Composition) | 嵌套的小節 | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
Composition.type | extensible | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | ||||
Composition.category | extensible | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 from the FHIR Standard | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
Composition.section.code | extensible | Pattern: LOINC Code 30954-2("Relevant diagnostic tests/laboratory data Narrative")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | 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 | error | Composition | 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 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from TWCoreComposition
Summary
Mandatory: 2 elements(8 nested mandatory elements)
Must-Support: 2 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from TWCoreComposition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | TWCoreComposition | 醫療影像及報告Composition | |
type | ||||
coding | 1..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Required Pattern: At least the following | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18782-3 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Radiology Study observation (narrative) | |
subject | 1..1 | Reference(醫療影像及報告-病患基本資料) | Composition是關於誰和/或什麼 | |
encounter | 0..1 | Reference(醫療影像及報告-醫囑時間) | Composition的情境 | |
date | 1..1 | dateTime | Composition編輯時間 | |
author | 1..1 | Reference(醫療影像及報告-醫事機構基本資料) | 什麼機構撰寫此醫療影像及報告 | |
title | 1..1 | string | 醫療影像及報告 | |
attester | 0..1 | BackboneElement | 證明Composition的準確性 | |
time | S | 0..1 | dateTime | Composition何時被證明 |
party | S | 1..1 | Reference(醫療影像及報告-醫事機構基本資料) | 誰證明這個Composition |
section | 0..* | BackboneElement | Section的標籤(例如:目錄) | |
code | 1..1 | CodeableConceptTW | 小節分類(建議) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Relevant diagnostic tests/laboratory data Narrative | |
coding | 1..* | CodingTW | 由專門術語系統(terminology system)定義的代碼 | |
text | 0..1 | Narrative | Section的摘要,供人解讀。 | |
Slices for entry | 5..* | Reference(Resource) | 提供一個連結用於參照或查看支持此小節內容的資料 Slice: Unordered, Open by profile:resolve() | |
entry:Practitioner | 1..1 | Reference(醫療影像及報告-醫事人員基本資料) | 支援這個section的資料之參照 | |
entry:Condition | 1..1 | Reference(醫療影像及報告-病史) | 支援這個section的資料之參照 | |
entry:Observation | 1..1 | Reference(醫療影像及報告-影像檢驗報告) | 支援這個section的資料之參照 | |
entry:DiagnosticReport | 1..1 | Reference(DiagnosticReport Image) | 支援這個section的資料之參照 | |
entry:ImagingStudy | 1..1 | Reference(醫療影像及報告-醫學影像內容) | 支援這個section的資料之參照 | |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | TWCoreComposition | 醫療影像及報告Composition | |
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 |
modifierExtension | ?! | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 |
identifier | SΣ | 0..1 | Identifier | 不分版本的臨床文件架構(Composition)識別碼。 |
status | ?!SΣ | 1..1 | code | registered | partial | preliminary | final | amended | corrected + Binding: CompositionStatus (required): Composition的工作流程/臨床狀態;應填入所綁定值集中的其中一個代碼。 |
type | S | 1..1 | CodeableConceptTW | Composition的種類(如果可能請使用LOINC) Binding: FHIRDocumentTypeCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 |
coding | S | 1..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Required Pattern: At least the following |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18782-3 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Radiology Study observation (narrative) | |
text | SΣ | 0..1 | string | 概念的文字表示法 |
subject | SΣ | 1..1 | Reference(醫療影像及報告-病患基本資料) | Composition是關於誰和/或什麼 |
encounter | Σ | 0..1 | Reference(醫療影像及報告-醫囑時間) | Composition的情境 |
date | SΣ | 1..1 | dateTime | Composition編輯時間 |
author | SΣ | 1..1 | Reference(醫療影像及報告-醫事機構基本資料) | 什麼機構撰寫此醫療影像及報告 |
title | SΣ | 1..1 | string | 醫療影像及報告 |
attester | S | 0..1 | BackboneElement | 證明Composition的準確性 |
modifierExtension | ?!Σ | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 |
mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): 認證者提供的認證類型;應填入所綁定值集中的其中一個代碼。 | |
time | S | 0..1 | dateTime | Composition何時被證明 |
party | S | 1..1 | Reference(醫療影像及報告-醫事機構基本資料) | 誰證明這個Composition |
custodian | SΣ | 0..1 | Reference(TW Core Organization) | 維護Composition的機構 |
section | SC | 0..* | BackboneElement | Section的標籤(例如:目錄) cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 |
code | S | 1..1 | CodeableConceptTW | 小節分類(建議) Binding: DocumentSectionCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Relevant diagnostic tests/laboratory data Narrative | |
coding | S | 1..* | CodingTW | 由專門術語系統(terminology system)定義的代碼 |
text | SΣ | 0..1 | string | 概念的文字表示法 |
text | SC | 0..1 | Narrative | Section的摘要,供人解讀。 |
Slices for entry | SC | 5..* | Reference(Resource) | 提供一個連結用於參照或查看支持此小節內容的資料 Slice: Unordered, Open by profile:resolve() |
entry:Practitioner | SC | 1..1 | Reference(醫療影像及報告-醫事人員基本資料) | 支援這個section的資料之參照 |
entry:Condition | SC | 1..1 | Reference(醫療影像及報告-病史) | 支援這個section的資料之參照 |
entry:Observation | SC | 1..1 | Reference(醫療影像及報告-影像檢驗報告) | 支援這個section的資料之參照 |
entry:DiagnosticReport | SC | 1..1 | Reference(DiagnosticReport Image) | 支援這個section的資料之參照 |
entry:ImagingStudy | SC | 1..1 | Reference(醫療影像及報告-醫學影像內容) | 支援這個section的資料之參照 |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | |
Composition.type | extensible | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | |
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | |
Composition.section.code | extensible | Pattern: LOINC Code 30954-2("Relevant diagnostic tests/laboratory data Narrative")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | 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 | error | Composition | 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 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Composition | 0..* | TWCoreComposition | 醫療影像及報告Composition | |||||
id | Σ | 0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的Composition紀錄,通常又稱為邏輯性ID。 | ||||
meta | Σ | 0..1 | Meta | 此Composition Resource的metadata | ||||
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 | ||||
language | 0..1 | code | 用以表述Composition Resource內容的語言 Binding: CommonLanguages (preferred): 人類語言;鼓勵使用所綁定值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。
Example Value: zh-TW | |||||
text | 0..1 | Narrative | Composition Resource之內容摘要以供人閱讀 | |||||
contained | 0..* | Resource | 內嵌的(contained)、行內的Resources | |||||
extension | 0..* | Extension | 擴充的資料項目 | |||||
modifierExtension | ?! | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 | ||||
identifier | SΣ | 0..1 | Identifier | 不分版本的臨床文件架構(Composition)識別碼。 | ||||
status | ?!SΣ | 1..1 | code | registered | partial | preliminary | final | amended | corrected + Binding: CompositionStatus (required): Composition的工作流程/臨床狀態;應填入所綁定值集中的其中一個代碼。 | ||||
type | S | 1..1 | CodeableConceptTW | Composition的種類(如果可能請使用LOINC) Binding: FHIRDocumentTypeCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 Slice: Unordered, Open by value:url | |||||
coding | S | 1..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18782-3 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Radiology Study observation (narrative) | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | SΣ | 0..1 | string | 概念的文字表示法 | ||||
category | 0..* | CodeableConceptTW | Composition的分類 Binding: DocumentClassValueSet (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | |||||
subject | SΣ | 1..1 | Reference(醫療影像及報告-病患基本資料) | Composition是關於誰和/或什麼 | ||||
encounter | Σ | 0..1 | Reference(醫療影像及報告-醫囑時間) | Composition的情境 | ||||
date | SΣ | 1..1 | dateTime | Composition編輯時間 | ||||
author | SΣ | 1..1 | Reference(醫療影像及報告-醫事機構基本資料) | 什麼機構撰寫此醫療影像及報告 | ||||
title | SΣ | 1..1 | string | 醫療影像及報告 | ||||
confidentiality | Σ | 0..1 | code | 根據特定技術領域的定義 Binding: v3.ConfidentialityClassification (2014-03-26) (required): 應填入所綁定值集中的其中一個代碼。 | ||||
attester | S | 0..1 | BackboneElement | 證明Composition的準確性 | ||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 | |||||
modifierExtension | ?!Σ | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 | ||||
mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): 認證者提供的認證類型;應填入所綁定值集中的其中一個代碼。 | |||||
time | S | 0..1 | dateTime | Composition何時被證明 | ||||
party | S | 1..1 | Reference(醫療影像及報告-醫事機構基本資料) | 誰證明這個Composition | ||||
custodian | SΣ | 0..1 | Reference(TW Core Organization) | 維護Composition的機構 | ||||
relatesTo | 0..* | BackboneElement | 與其他Composition/文件之間的關係 | |||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 | |||||
modifierExtension | ?!Σ | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 | ||||
code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): 檔案之間的關係型別;應填入所綁定值集中的其中一個代碼。 | |||||
target[x] | 1..1 | 此關係的目標文件 | ||||||
targetIdentifier | Identifier | |||||||
targetReference | Reference(Composition) | |||||||
event | Σ | 0..* | BackboneElement | 正在記錄的臨床服務 | ||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 | |||||
modifierExtension | ?!Σ | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 | ||||
code | 0..* | CodeableConceptTW | 此代碼表代表了正在被記錄的主要臨床行為 Binding: v3 Code System ActCode (example): 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。 | |||||
period | Σ | 0..1 | Period | 文件所涵蓋的時間區間 | ||||
detail | Σ | 0..* | Reference(Resource) | 在描述被記錄下來的事件,這些事件可以是以代碼的形式、參考資料的形式,或者兩者都有的形式來呈現。 | ||||
section | SC | 0..* | BackboneElement | Section的標籤(例如:目錄) cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 | |||||
modifierExtension | ?!Σ | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 | ||||
title | 0..1 | string | 小節標籤(例如:目錄ToC) | |||||
code | S | 1..1 | CodeableConceptTW | 小節分類(建議) Binding: DocumentSectionCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Relevant diagnostic tests/laboratory data Narrative | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 Slice: Unordered, Open by value:url | |||||
coding | S | 1..* | CodingTW | 由專門術語系統(terminology system)定義的代碼 | ||||
text | SΣ | 0..1 | string | 概念的文字表示法 | ||||
author | 0..* | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | TW Core Patient | Device | RelatedPerson) | 誰和/或什麼人撰寫了該小節 | |||||
focus | 0..1 | Reference(Resource) | 當小節與composition描述的對象無關時,此小節是關於誰/什麼。 | |||||
text | SC | 0..1 | Narrative | Section的摘要,供人解讀。 | ||||
mode | 0..1 | code | 適用於此小節的處理模式 Binding: ListMode (required): 應填入所綁定值集中的其中一個代碼。 | |||||
orderedBy | 0..1 | CodeableConceptTW | 小節條目的順序 Binding: ListOrderCodes (preferred): 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。 | |||||
Slices for entry | SC | 5..* | Reference(Resource) | 提供一個連結用於參照或查看支持此小節內容的資料 Slice: Unordered, Open by profile:resolve() | ||||
entry:Practitioner | SC | 1..1 | Reference(醫療影像及報告-醫事人員基本資料) | 支援這個section的資料之參照 | ||||
entry:Condition | SC | 1..1 | Reference(醫療影像及報告-病史) | 支援這個section的資料之參照 | ||||
entry:Observation | SC | 1..1 | Reference(醫療影像及報告-影像檢驗報告) | 支援這個section的資料之參照 | ||||
entry:DiagnosticReport | SC | 1..1 | Reference(DiagnosticReport Image) | 支援這個section的資料之參照 | ||||
entry:ImagingStudy | SC | 1..1 | Reference(醫療影像及報告-醫學影像內容) | 支援這個section的資料之參照 | ||||
emptyReason | 0..1 | CodeableConceptTW | 為什麼此小節是空的原因 Binding: ListEmptyReasons (preferred): 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。 | |||||
section | C | 0..* | See section (Composition) | 嵌套的小節 | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
Composition.type | extensible | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | ||||
Composition.category | extensible | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 from the FHIR Standard | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
Composition.section.code | extensible | Pattern: LOINC Code 30954-2("Relevant diagnostic tests/laboratory data Narrative")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | 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 | error | Composition | 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 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from TWCoreComposition
Summary
Mandatory: 2 elements(8 nested mandatory elements)
Must-Support: 2 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron