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: 醫療影像及報告-Composition

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:

Formal Views of Profile Content

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

This structure is derived from TWCoreComposition

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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。
... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
Composition.typeextensibleFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes
from the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.section.codeextensiblePattern: LOINC Code 30954-2("Relevant diagnostic tests/laboratory data Narrative")
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.sectionA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf 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-4errorCompositionIf 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-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
Composition.typeextensibleFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes
from the FHIR Standard
Composition.categoryextensibleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
Composition.confidentialityrequiredv3.ConfidentialityClassification
http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26
from the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
Composition.event.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.codeextensiblePattern: LOINC Code 30954-2("Relevant diagnostic tests/laboratory data Narrative")
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
from the FHIR Standard
Composition.section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
from the FHIR Standard
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.sectionA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf 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-4errorCompositionIf 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-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from TWCoreComposition

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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。
... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
Composition.typeextensibleFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes
from the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.section.codeextensiblePattern: LOINC Code 30954-2("Relevant diagnostic tests/laboratory data Narrative")
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.sectionA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf 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-4errorCompositionIf 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-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
Composition.typeextensibleFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes
from the FHIR Standard
Composition.categoryextensibleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
Composition.confidentialityrequiredv3.ConfidentialityClassification
http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26
from the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
Composition.event.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.codeextensiblePattern: LOINC Code 30954-2("Relevant diagnostic tests/laboratory data Narrative")
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
from the FHIR Standard
Composition.section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
from the FHIR Standard
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.sectionA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf 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-4errorCompositionIf 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-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron