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/Observation-DS-BodyWeight | Version: 0.1.0 | |||
Draft as of 2024-01-02 | Computable Name: ObservationDSBodyWeight |
此Profiles繼承於臺灣核心-生命體徵(TW Core Observation Vital Signs) Profile,並進一步用於描述調劑單張之病患體重。 若調劑藥物劑量須配合體重而有所調整,此Profiles為必填。 [FMM1]
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from TWCoreObservationVitalSigns
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 0..* | TWCoreObservationVitalSigns | 檢驗檢查,測量及簡單的判定。 | |
code | ||||
coding | ||||
system | 0..1 | uri | 專門術語系統(terminology system)的識別 Fixed Value: http://loinc.org | |
code | 0..1 | code | 系統定義的語法之符號 Fixed Value: 29463-7 | |
display | 0..1 | string | 由系統定義的表示法 Fixed Value: Body weight | |
subject | 1..1 | Reference(調劑單張-病人基本資料) | 檢驗檢查有關的對象及(或)事物 | |
encounter | 0..1 | Reference(調劑單張-門診基本資料) | 檢驗檢查是哪一次就醫時執行的 | |
Slices for value[x] | 1..1 | Quantity | 檢驗檢查的實際結果 Slice: Unordered, Open by type:$this | |
value[x]:valueQuantity | 1..1 | Quantity | 檢驗檢查的實際結果。[應填入體重 Weight]。若調劑藥物劑量須配合體重而有所調整,此欄位為必填 | |
value | S | 1..1 | decimal | Numerical value (with implicit precision) |
unit | S | 0..1 | string | Unit representation Required Pattern: kg |
system | 0..1 | uri | System that defines coded unit form Required Pattern: http://unitsofmeasure.org | |
code | 0..1 | code | Coded form of the unit Required Pattern: kg | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | TWCoreObservationVitalSigns | 檢驗檢查,測量及簡單的判定。 obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present vs-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present. |
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。 |
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): 檢驗檢查的狀態代碼;應填入所綁定值集中的其中一個代碼。 |
Slices for category | S | 1..* | CodeableConceptTW | 概念(concept)-參照一個專門術語或只是純文字。 Slice: Unordered, Open by value:coding.code, value:coding.system Binding: ObservationCategoryCodes (preferred): 高層次的檢驗檢查分類;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。 |
category:VSCat | S | 1..1 | CodeableConceptTW | 檢驗檢查分類 Binding: ObservationCategoryCodes (preferred): 高層次的檢驗檢查分類;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。 |
coding | SΣ | 1..* | Coding | 由專門術語系統(terminology system)定義的代碼 |
system | SΣ | 1..1 | uri | 專門術語系統(terminology system)的識別 Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category |
code | SΣ | 1..1 | code | 系統定義的語法之符號 Fixed Value: vital-signs |
code | S | 1..1 | CodeableConceptTW | 概念(concept)-參照一個專門術語或只是純文字。 Binding: VitalSigns (extensible): 應填入所綁定值集中的其中一個代碼。 |
coding | S | 0..* | CodingTW | 由專門術語系統(terminology system)定義的代碼 |
system | SΣ | 0..1 | uri | 專門術語系統(terminology system)的識別 Fixed Value: http://loinc.org |
code | SΣ | 0..1 | code | 系統定義的語法之符號 Fixed Value: 29463-7 |
display | SΣ | 0..1 | string | 由系統定義的表示法 Fixed Value: Body weight |
text | SΣ | 0..1 | string | 概念的文字表示法 |
subject | SΣ | 1..1 | Reference(調劑單張-病人基本資料) | 檢驗檢查有關的對象及(或)事物 |
encounter | Σ | 0..1 | Reference(調劑單張-門診基本資料) | 檢驗檢查是哪一次就醫時執行的 |
effective[x] | SΣC | 1..1 | 檢驗檢查執行日期或時間區間 vs-1: if Observation.effective[x] is dateTime and has a value then that value shall be precise to the day | |
effectiveDateTime | dateTime | |||
performer | SΣ | 0..* | Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | TW Core PractitionerRole | CareTeam) | 誰負責這項檢驗檢查 |
Slices for value[x] | SΣC | 1..1 | Quantity | 檢驗檢查的實際結果 Slice: Unordered, Closed by type:$this Binding: VitalSignsUnits (extensible): 用於記錄生命體徵的常用UCUM單元;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。 |
value[x]:valueQuantity | SΣC | 1..1 | Quantity | 檢驗檢查的實際結果。[應填入體重 Weight]。若調劑藥物劑量須配合體重而有所調整,此欄位為必填 Binding: VitalSignsUnits (extensible): 用於記錄生命體徵的常用UCUM單元;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。 |
value | SΣ | 1..1 | decimal | Numerical value (with implicit precision) |
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented. |
unit | SΣ | 0..1 | string | Unit representation Required Pattern: kg |
system | ΣC | 0..1 | uri | System that defines coded unit form Required Pattern: http://unitsofmeasure.org |
code | Σ | 0..1 | code | Coded form of the unit Required Pattern: kg |
dataAbsentReason | S | 0..1 | CodeableConceptTW | 缺少檢驗檢查結果的原因 Binding: DataAbsentReason (extensible): 代碼具體說明檢驗檢查結果缺少的原因;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。 |
component | SΣC | 0..* | BackboneElement | 組成之(部分)檢驗檢查的檢驗結果 vs-3: If there is no a value a data absent reason must be present |
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 | 組成之檢驗檢查的型別(代碼/型別) Binding: 生命體徵值集 (required): 代碼指明檢驗檢查的名稱;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。 |
value[x] | SΣC | 0..1 | Vital Sign Value recorded with UCUM Binding: VitalSignsUnits (required): Common UCUM units for recording Vital Signs. | |
valueQuantity | Quantity | |||
dataAbsentReason | S | 0..1 | CodeableConceptTW | 為什麼缺少組成之檢驗檢查結果 Binding: DataAbsentReason (extensible): 代碼指明為什麼結果(Observation.value[x])缺少;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。 |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | |
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.category:VSCat | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.code | extensible | VitalSignshttp://hl7.org/fhir/ValueSet/observation-vitalsignresult from the FHIR Standard | |
Observation.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common from the FHIR Standard | |
Observation.value[x]:valueQuantity | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common from the FHIR Standard | |
Observation.value[x]:valueQuantity.comparator | required | QuantityComparatorhttp://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard | |
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | |
Observation.component.code | required | TWVitalSignshttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/vital-signs-tw | |
Observation.component.value[x] | required | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1 from the FHIR Standard | |
Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Observation | 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 | Observation | 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 | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Observation | 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() | |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
vs-1 | error | Observation.effective[x] | if Observation.effective[x] is dateTime and has a value then that value shall be precise to the day : $this is dateTime implies $this.toString().length() >= 10 | |
vs-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present. : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
vs-3 | error | Observation.component | If there is no a value a data absent reason must be present : value.exists() or dataAbsentReason.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | TWCoreObservationVitalSigns | 檢驗檢查,測量及簡單的判定。 obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present vs-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present. | ||||
id | Σ | 0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的Observation紀錄,通常又稱為邏輯性ID。 | ||||
meta | Σ | 0..1 | Meta | 此Observation 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Observation Resource內容的語言。 Binding: CommonLanguages (preferred): 人類語言;鼓勵使用CommonLanguages代碼表中的代碼,但不強制一定要使用此代碼表,你也可使用其他代碼表的代碼或單純以文字表示。
Example Value: zh-TW | |||||
text | 0..1 | Narrative | Observation 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 | Σ | 0..* | Identifier | 檢驗檢查的識別碼,通常為業務目的所使用的識別碼,例如:檢驗序號或單號。 | ||||
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | TW Core MedicationRequest | NutritionOrder | ServiceRequest) | 依據的照護計畫/提議/醫令 | ||||
partOf | Σ | 0..* | Reference(MedicationAdministration | TW Core MedicationDispense | TW Core MedicationStatement | TW Core Procedure | Immunization | TW Core ImagingStudy) | 此檢驗檢查是哪個參照事件的一部分 | ||||
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): 檢驗檢查的狀態代碼;應填入所綁定值集中的其中一個代碼。 | ||||
Slices for category | S | 1..* | CodeableConceptTW | 概念(concept)-參照一個專門術語或只是純文字。 Slice: Unordered, Open by value:coding.code, value:coding.system Binding: ObservationCategoryCodes (preferred): 高層次的檢驗檢查分類;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。 | ||||
category:VSCat | S | 1..1 | CodeableConceptTW | 檢驗檢查分類 Binding: ObservationCategoryCodes (preferred): 高層次的檢驗檢查分類;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。 | ||||
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 | SΣ | 1..* | Coding | 由專門術語系統(terminology system)定義的代碼 | ||||
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 | |||||
system | SΣ | 1..1 | uri | 專門術語系統(terminology system)的識別 Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | ||||
version | Σ | 0..1 | string | 系統的版本—如果相關的話 | ||||
code | SΣ | 1..1 | code | 系統定義的語法之符號 Fixed Value: vital-signs | ||||
display | Σ | 0..1 | string | 由系統定義的表示法 | ||||
userSelected | Σ | 0..1 | boolean | 此編碼是否由使用者直接選擇? | ||||
text | Σ | 0..1 | string | 概念的文字表示法 | ||||
code | S | 1..1 | CodeableConceptTW | 概念(concept)-參照一個專門術語或只是純文字。 Binding: VitalSigns (extensible): 應填入所綁定值集中的其中一個代碼。 | ||||
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 | 0..* | CodingTW | 由專門術語系統(terminology system)定義的代碼 | ||||
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 | |||||
system | SΣ | 0..1 | uri | 專門術語系統(terminology system)的識別 Fixed Value: http://loinc.org | ||||
version | Σ | 0..1 | string | 系統的版本—如果相關的話 | ||||
code | SΣ | 0..1 | code | 系統定義的語法之符號 Fixed Value: 29463-7 | ||||
display | SΣ | 0..1 | string | 由系統定義的表示法 Fixed Value: Body weight | ||||
userSelected | Σ | 0..1 | boolean | 此編碼是否由使用者直接選擇? | ||||
text | SΣ | 0..1 | string | 概念的文字表示法 | ||||
subject | SΣ | 1..1 | Reference(調劑單張-病人基本資料) | 檢驗檢查有關的對象及(或)事物 | ||||
focus | Σ | 0..* | Reference(Resource) | 當檢驗檢查並非有關於與病人本身,檢驗檢查是關於什麼。 | ||||
encounter | Σ | 0..1 | Reference(調劑單張-門診基本資料) | 檢驗檢查是哪一次就醫時執行的 | ||||
effective[x] | SΣC | 1..1 | 檢驗檢查執行日期或時間區間 vs-1: if Observation.effective[x] is dateTime and has a value then that value shall be precise to the day | |||||
effectiveDateTime | dateTime S | |||||||
effectivePeriod | Period | |||||||
issued | Σ | 0..1 | instant | 此版本檢驗檢查完成的日期或時間 | ||||
performer | SΣ | 0..* | Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | TW Core PractitionerRole | CareTeam) | 誰負責這項檢驗檢查 | ||||
Slices for value[x] | SΣC | 1..1 | Quantity S | 檢驗檢查的實際結果 Slice: Unordered, Closed by type:$this Binding: VitalSignsUnits (extensible): 用於記錄生命體徵的常用UCUM單元;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。 | ||||
value[x]:valueQuantity | SΣC | 1..1 | Quantity S | 檢驗檢查的實際結果。[應填入體重 Weight]。若調劑藥物劑量須配合體重而有所調整,此欄位為必填 Binding: VitalSignsUnits (extensible): 用於記錄生命體徵的常用UCUM單元;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 | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
value | SΣ | 1..1 | decimal | Numerical value (with implicit precision) | ||||
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented. | ||||
unit | SΣ | 0..1 | string | Unit representation Required Pattern: kg | ||||
system | ΣC | 0..1 | uri | System that defines coded unit form Required Pattern: http://unitsofmeasure.org | ||||
code | Σ | 0..1 | code | Coded form of the unit Required Pattern: kg | ||||
dataAbsentReason | S | 0..1 | CodeableConceptTW | 缺少檢驗檢查結果的原因 Binding: DataAbsentReason (extensible): 代碼具體說明檢驗檢查結果缺少的原因;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。 | ||||
interpretation | 0..* | CodeableConceptTW | 高、低、正常等 Binding: ObservationInterpretationCodes (extensible): 代碼指明檢驗檢查結果的解釋;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。 | |||||
note | 0..* | Annotation | 關於此檢驗檢查之解說 | |||||
bodySite | 0..1 | CodeableConceptTW | 接受檢驗檢查的身體部位。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。 Binding: SNOMEDCTBodyStructures (extensible): 代碼說明解剖學位置,可能包含側邊;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。 | |||||
method | 0..1 | CodeableConceptTW | 此檢驗檢查使用何種方法完成 Binding: ObservationMethods (extensible): 檢驗檢查的方法;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。 | |||||
specimen | 0..1 | Reference(TW Core Specimen) | 此檢驗檢查的檢體 | |||||
device | 0..1 | Reference(Device | DeviceMetric) | (測量)設備 | |||||
referenceRange | C | 0..* | BackboneElement | 解釋結果值的指引。
obs-3:必須至少有低、高或文字表述。 obs-3: Must have at least a low or a high or text | ||||
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。 | ||||
low | C | 0..1 | SimpleQuantity | 參考範圍值的下限值,如果相關。 | ||||
high | C | 0..1 | SimpleQuantity | 參考範圍值的上限值,如果相關。 | ||||
type | 0..1 | CodeableConceptTW | 參考範圍值的限定詞 Binding: ObservationReferenceRangeMeaningCodes (preferred): 用以表述參考範圍值之含意的代碼;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。 | |||||
appliesTo | 0..* | CodeableConceptTW | 參考範圍值是用適用的對象或人口群 Binding: ObservationReferenceRangeAppliesToCodes (example): 用以指明參考範圍值適用的對象或人口群之代碼;可參考所綁定代碼表,但此代碼表只是針對這個欄位的一個可能值的示例,不預期也不鼓勵使用者一定要使用此代碼表的代碼代碼表中的代碼。 | |||||
age | 0..1 | Range | 適用的年齡範圍值,如果相關。 | |||||
text | 0..1 | string | 檢驗檢查中以文字表述的參考範圍值 | |||||
hasMember | Σ | 0..* | Reference(TW Core Observation Vital Signs | QuestionnaireResponse | MolecularSequence) | 屬於此組檢驗檢查的相關Resource | ||||
derivedFrom | Σ | 0..* | Reference(TW Core DocumentReference | TW Core ImagingStudy | TW Core Media | QuestionnaireResponse | TW Core Observation Vital Signs | MolecularSequence) | 檢驗檢查源自哪些相關測量 | ||||
component | SΣC | 0..* | BackboneElement | 組成之(部分)檢驗檢查的檢驗結果 vs-3: If there is no a value a data absent reason must be present | ||||
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 | S | 1..1 | CodeableConceptTW | 組成之檢驗檢查的型別(代碼/型別) Binding: 生命體徵值集 (required): 代碼指明檢驗檢查的名稱;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。 | ||||
value[x] | SΣC | 0..1 | Vital Sign Value recorded with UCUM Binding: VitalSignsUnits (required): Common UCUM units for recording Vital Signs. | |||||
valueQuantity | Quantity S | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
dataAbsentReason | S | 0..1 | CodeableConceptTW | 為什麼缺少組成之檢驗檢查結果 Binding: DataAbsentReason (extensible): 代碼指明為什麼結果(Observation.value[x])缺少;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。 | ||||
interpretation | 0..* | CodeableConceptTW | 高、低、正常等。 Binding: ObservationInterpretationCodes (extensible): 用以指明檢驗檢查的解釋之代碼。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。 | |||||
referenceRange | 0..* | See referenceRange (Observation) | 解釋此組成之檢驗驗查的結果值之指引 | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Observation.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | ||||
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.category:VSCat | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.code | extensible | VitalSignshttp://hl7.org/fhir/ValueSet/observation-vitalsignresult from the FHIR Standard | ||||
Observation.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common from the FHIR Standard | ||||
Observation.value[x]:valueQuantity | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common from the FHIR Standard | ||||
Observation.value[x]:valueQuantity.comparator | required | QuantityComparatorhttp://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard | ||||
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard | ||||
Observation.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Observation.method | extensible | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methods from the FHIR Standard | ||||
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaning from the FHIR Standard | ||||
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliesto from the FHIR Standard | ||||
Observation.component.code | required | TWVitalSignshttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/vital-signs-tw | ||||
Observation.component.value[x] | required | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1 from the FHIR Standard | ||||
Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Observation | 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 | Observation | 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 | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Observation | 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() | |
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
vs-1 | error | Observation.effective[x] | if Observation.effective[x] is dateTime and has a value then that value shall be precise to the day : $this is dateTime implies $this.toString().length() >= 10 | |
vs-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present. : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
vs-3 | error | Observation.component | If there is no a value a data absent reason must be present : value.exists() or dataAbsentReason.exists() |
This structure is derived from TWCoreObservationVitalSigns
Summary
Mandatory: 3 elements
Must-Support: 2 elements
Fixed: 3 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from TWCoreObservationVitalSigns
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 0..* | TWCoreObservationVitalSigns | 檢驗檢查,測量及簡單的判定。 | |
code | ||||
coding | ||||
system | 0..1 | uri | 專門術語系統(terminology system)的識別 Fixed Value: http://loinc.org | |
code | 0..1 | code | 系統定義的語法之符號 Fixed Value: 29463-7 | |
display | 0..1 | string | 由系統定義的表示法 Fixed Value: Body weight | |
subject | 1..1 | Reference(調劑單張-病人基本資料) | 檢驗檢查有關的對象及(或)事物 | |
encounter | 0..1 | Reference(調劑單張-門診基本資料) | 檢驗檢查是哪一次就醫時執行的 | |
Slices for value[x] | 1..1 | Quantity | 檢驗檢查的實際結果 Slice: Unordered, Open by type:$this | |
value[x]:valueQuantity | 1..1 | Quantity | 檢驗檢查的實際結果。[應填入體重 Weight]。若調劑藥物劑量須配合體重而有所調整,此欄位為必填 | |
value | S | 1..1 | decimal | Numerical value (with implicit precision) |
unit | S | 0..1 | string | Unit representation Required Pattern: kg |
system | 0..1 | uri | System that defines coded unit form Required Pattern: http://unitsofmeasure.org | |
code | 0..1 | code | Coded form of the unit Required Pattern: kg | |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | TWCoreObservationVitalSigns | 檢驗檢查,測量及簡單的判定。 obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present vs-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present. |
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。 |
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): 檢驗檢查的狀態代碼;應填入所綁定值集中的其中一個代碼。 |
Slices for category | S | 1..* | CodeableConceptTW | 概念(concept)-參照一個專門術語或只是純文字。 Slice: Unordered, Open by value:coding.code, value:coding.system Binding: ObservationCategoryCodes (preferred): 高層次的檢驗檢查分類;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。 |
category:VSCat | S | 1..1 | CodeableConceptTW | 檢驗檢查分類 Binding: ObservationCategoryCodes (preferred): 高層次的檢驗檢查分類;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。 |
coding | SΣ | 1..* | Coding | 由專門術語系統(terminology system)定義的代碼 |
system | SΣ | 1..1 | uri | 專門術語系統(terminology system)的識別 Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category |
code | SΣ | 1..1 | code | 系統定義的語法之符號 Fixed Value: vital-signs |
code | S | 1..1 | CodeableConceptTW | 概念(concept)-參照一個專門術語或只是純文字。 Binding: VitalSigns (extensible): 應填入所綁定值集中的其中一個代碼。 |
coding | S | 0..* | CodingTW | 由專門術語系統(terminology system)定義的代碼 |
system | SΣ | 0..1 | uri | 專門術語系統(terminology system)的識別 Fixed Value: http://loinc.org |
code | SΣ | 0..1 | code | 系統定義的語法之符號 Fixed Value: 29463-7 |
display | SΣ | 0..1 | string | 由系統定義的表示法 Fixed Value: Body weight |
text | SΣ | 0..1 | string | 概念的文字表示法 |
subject | SΣ | 1..1 | Reference(調劑單張-病人基本資料) | 檢驗檢查有關的對象及(或)事物 |
encounter | Σ | 0..1 | Reference(調劑單張-門診基本資料) | 檢驗檢查是哪一次就醫時執行的 |
effective[x] | SΣC | 1..1 | 檢驗檢查執行日期或時間區間 vs-1: if Observation.effective[x] is dateTime and has a value then that value shall be precise to the day | |
effectiveDateTime | dateTime | |||
performer | SΣ | 0..* | Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | TW Core PractitionerRole | CareTeam) | 誰負責這項檢驗檢查 |
Slices for value[x] | SΣC | 1..1 | Quantity | 檢驗檢查的實際結果 Slice: Unordered, Closed by type:$this Binding: VitalSignsUnits (extensible): 用於記錄生命體徵的常用UCUM單元;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。 |
value[x]:valueQuantity | SΣC | 1..1 | Quantity | 檢驗檢查的實際結果。[應填入體重 Weight]。若調劑藥物劑量須配合體重而有所調整,此欄位為必填 Binding: VitalSignsUnits (extensible): 用於記錄生命體徵的常用UCUM單元;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。 |
value | SΣ | 1..1 | decimal | Numerical value (with implicit precision) |
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented. |
unit | SΣ | 0..1 | string | Unit representation Required Pattern: kg |
system | ΣC | 0..1 | uri | System that defines coded unit form Required Pattern: http://unitsofmeasure.org |
code | Σ | 0..1 | code | Coded form of the unit Required Pattern: kg |
dataAbsentReason | S | 0..1 | CodeableConceptTW | 缺少檢驗檢查結果的原因 Binding: DataAbsentReason (extensible): 代碼具體說明檢驗檢查結果缺少的原因;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。 |
component | SΣC | 0..* | BackboneElement | 組成之(部分)檢驗檢查的檢驗結果 vs-3: If there is no a value a data absent reason must be present |
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 | 組成之檢驗檢查的型別(代碼/型別) Binding: 生命體徵值集 (required): 代碼指明檢驗檢查的名稱;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。 |
value[x] | SΣC | 0..1 | Vital Sign Value recorded with UCUM Binding: VitalSignsUnits (required): Common UCUM units for recording Vital Signs. | |
valueQuantity | Quantity | |||
dataAbsentReason | S | 0..1 | CodeableConceptTW | 為什麼缺少組成之檢驗檢查結果 Binding: DataAbsentReason (extensible): 代碼指明為什麼結果(Observation.value[x])缺少;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。 |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | |
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.category:VSCat | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.code | extensible | VitalSignshttp://hl7.org/fhir/ValueSet/observation-vitalsignresult from the FHIR Standard | |
Observation.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common from the FHIR Standard | |
Observation.value[x]:valueQuantity | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common from the FHIR Standard | |
Observation.value[x]:valueQuantity.comparator | required | QuantityComparatorhttp://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard | |
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | |
Observation.component.code | required | TWVitalSignshttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/vital-signs-tw | |
Observation.component.value[x] | required | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1 from the FHIR Standard | |
Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Observation | 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 | Observation | 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 | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Observation | 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() | |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
vs-1 | error | Observation.effective[x] | if Observation.effective[x] is dateTime and has a value then that value shall be precise to the day : $this is dateTime implies $this.toString().length() >= 10 | |
vs-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present. : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
vs-3 | error | Observation.component | If there is no a value a data absent reason must be present : value.exists() or dataAbsentReason.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | TWCoreObservationVitalSigns | 檢驗檢查,測量及簡單的判定。 obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present vs-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present. | ||||
id | Σ | 0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的Observation紀錄,通常又稱為邏輯性ID。 | ||||
meta | Σ | 0..1 | Meta | 此Observation 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Observation Resource內容的語言。 Binding: CommonLanguages (preferred): 人類語言;鼓勵使用CommonLanguages代碼表中的代碼,但不強制一定要使用此代碼表,你也可使用其他代碼表的代碼或單純以文字表示。
Example Value: zh-TW | |||||
text | 0..1 | Narrative | Observation 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 | Σ | 0..* | Identifier | 檢驗檢查的識別碼,通常為業務目的所使用的識別碼,例如:檢驗序號或單號。 | ||||
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | TW Core MedicationRequest | NutritionOrder | ServiceRequest) | 依據的照護計畫/提議/醫令 | ||||
partOf | Σ | 0..* | Reference(MedicationAdministration | TW Core MedicationDispense | TW Core MedicationStatement | TW Core Procedure | Immunization | TW Core ImagingStudy) | 此檢驗檢查是哪個參照事件的一部分 | ||||
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): 檢驗檢查的狀態代碼;應填入所綁定值集中的其中一個代碼。 | ||||
Slices for category | S | 1..* | CodeableConceptTW | 概念(concept)-參照一個專門術語或只是純文字。 Slice: Unordered, Open by value:coding.code, value:coding.system Binding: ObservationCategoryCodes (preferred): 高層次的檢驗檢查分類;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。 | ||||
category:VSCat | S | 1..1 | CodeableConceptTW | 檢驗檢查分類 Binding: ObservationCategoryCodes (preferred): 高層次的檢驗檢查分類;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。 | ||||
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 | SΣ | 1..* | Coding | 由專門術語系統(terminology system)定義的代碼 | ||||
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 | |||||
system | SΣ | 1..1 | uri | 專門術語系統(terminology system)的識別 Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | ||||
version | Σ | 0..1 | string | 系統的版本—如果相關的話 | ||||
code | SΣ | 1..1 | code | 系統定義的語法之符號 Fixed Value: vital-signs | ||||
display | Σ | 0..1 | string | 由系統定義的表示法 | ||||
userSelected | Σ | 0..1 | boolean | 此編碼是否由使用者直接選擇? | ||||
text | Σ | 0..1 | string | 概念的文字表示法 | ||||
code | S | 1..1 | CodeableConceptTW | 概念(concept)-參照一個專門術語或只是純文字。 Binding: VitalSigns (extensible): 應填入所綁定值集中的其中一個代碼。 | ||||
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 | 0..* | CodingTW | 由專門術語系統(terminology system)定義的代碼 | ||||
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 | |||||
system | SΣ | 0..1 | uri | 專門術語系統(terminology system)的識別 Fixed Value: http://loinc.org | ||||
version | Σ | 0..1 | string | 系統的版本—如果相關的話 | ||||
code | SΣ | 0..1 | code | 系統定義的語法之符號 Fixed Value: 29463-7 | ||||
display | SΣ | 0..1 | string | 由系統定義的表示法 Fixed Value: Body weight | ||||
userSelected | Σ | 0..1 | boolean | 此編碼是否由使用者直接選擇? | ||||
text | SΣ | 0..1 | string | 概念的文字表示法 | ||||
subject | SΣ | 1..1 | Reference(調劑單張-病人基本資料) | 檢驗檢查有關的對象及(或)事物 | ||||
focus | Σ | 0..* | Reference(Resource) | 當檢驗檢查並非有關於與病人本身,檢驗檢查是關於什麼。 | ||||
encounter | Σ | 0..1 | Reference(調劑單張-門診基本資料) | 檢驗檢查是哪一次就醫時執行的 | ||||
effective[x] | SΣC | 1..1 | 檢驗檢查執行日期或時間區間 vs-1: if Observation.effective[x] is dateTime and has a value then that value shall be precise to the day | |||||
effectiveDateTime | dateTime S | |||||||
effectivePeriod | Period | |||||||
issued | Σ | 0..1 | instant | 此版本檢驗檢查完成的日期或時間 | ||||
performer | SΣ | 0..* | Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | TW Core PractitionerRole | CareTeam) | 誰負責這項檢驗檢查 | ||||
Slices for value[x] | SΣC | 1..1 | Quantity S | 檢驗檢查的實際結果 Slice: Unordered, Closed by type:$this Binding: VitalSignsUnits (extensible): 用於記錄生命體徵的常用UCUM單元;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。 | ||||
value[x]:valueQuantity | SΣC | 1..1 | Quantity S | 檢驗檢查的實際結果。[應填入體重 Weight]。若調劑藥物劑量須配合體重而有所調整,此欄位為必填 Binding: VitalSignsUnits (extensible): 用於記錄生命體徵的常用UCUM單元;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 | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
value | SΣ | 1..1 | decimal | Numerical value (with implicit precision) | ||||
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented. | ||||
unit | SΣ | 0..1 | string | Unit representation Required Pattern: kg | ||||
system | ΣC | 0..1 | uri | System that defines coded unit form Required Pattern: http://unitsofmeasure.org | ||||
code | Σ | 0..1 | code | Coded form of the unit Required Pattern: kg | ||||
dataAbsentReason | S | 0..1 | CodeableConceptTW | 缺少檢驗檢查結果的原因 Binding: DataAbsentReason (extensible): 代碼具體說明檢驗檢查結果缺少的原因;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。 | ||||
interpretation | 0..* | CodeableConceptTW | 高、低、正常等 Binding: ObservationInterpretationCodes (extensible): 代碼指明檢驗檢查結果的解釋;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。 | |||||
note | 0..* | Annotation | 關於此檢驗檢查之解說 | |||||
bodySite | 0..1 | CodeableConceptTW | 接受檢驗檢查的身體部位。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。 Binding: SNOMEDCTBodyStructures (extensible): 代碼說明解剖學位置,可能包含側邊;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。 | |||||
method | 0..1 | CodeableConceptTW | 此檢驗檢查使用何種方法完成 Binding: ObservationMethods (extensible): 檢驗檢查的方法;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。 | |||||
specimen | 0..1 | Reference(TW Core Specimen) | 此檢驗檢查的檢體 | |||||
device | 0..1 | Reference(Device | DeviceMetric) | (測量)設備 | |||||
referenceRange | C | 0..* | BackboneElement | 解釋結果值的指引。
obs-3:必須至少有低、高或文字表述。 obs-3: Must have at least a low or a high or text | ||||
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。 | ||||
low | C | 0..1 | SimpleQuantity | 參考範圍值的下限值,如果相關。 | ||||
high | C | 0..1 | SimpleQuantity | 參考範圍值的上限值,如果相關。 | ||||
type | 0..1 | CodeableConceptTW | 參考範圍值的限定詞 Binding: ObservationReferenceRangeMeaningCodes (preferred): 用以表述參考範圍值之含意的代碼;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。 | |||||
appliesTo | 0..* | CodeableConceptTW | 參考範圍值是用適用的對象或人口群 Binding: ObservationReferenceRangeAppliesToCodes (example): 用以指明參考範圍值適用的對象或人口群之代碼;可參考所綁定代碼表,但此代碼表只是針對這個欄位的一個可能值的示例,不預期也不鼓勵使用者一定要使用此代碼表的代碼代碼表中的代碼。 | |||||
age | 0..1 | Range | 適用的年齡範圍值,如果相關。 | |||||
text | 0..1 | string | 檢驗檢查中以文字表述的參考範圍值 | |||||
hasMember | Σ | 0..* | Reference(TW Core Observation Vital Signs | QuestionnaireResponse | MolecularSequence) | 屬於此組檢驗檢查的相關Resource | ||||
derivedFrom | Σ | 0..* | Reference(TW Core DocumentReference | TW Core ImagingStudy | TW Core Media | QuestionnaireResponse | TW Core Observation Vital Signs | MolecularSequence) | 檢驗檢查源自哪些相關測量 | ||||
component | SΣC | 0..* | BackboneElement | 組成之(部分)檢驗檢查的檢驗結果 vs-3: If there is no a value a data absent reason must be present | ||||
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 | S | 1..1 | CodeableConceptTW | 組成之檢驗檢查的型別(代碼/型別) Binding: 生命體徵值集 (required): 代碼指明檢驗檢查的名稱;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。 | ||||
value[x] | SΣC | 0..1 | Vital Sign Value recorded with UCUM Binding: VitalSignsUnits (required): Common UCUM units for recording Vital Signs. | |||||
valueQuantity | Quantity S | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
dataAbsentReason | S | 0..1 | CodeableConceptTW | 為什麼缺少組成之檢驗檢查結果 Binding: DataAbsentReason (extensible): 代碼指明為什麼結果(Observation.value[x])缺少;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。 | ||||
interpretation | 0..* | CodeableConceptTW | 高、低、正常等。 Binding: ObservationInterpretationCodes (extensible): 用以指明檢驗檢查的解釋之代碼。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。 | |||||
referenceRange | 0..* | See referenceRange (Observation) | 解釋此組成之檢驗驗查的結果值之指引 | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Observation.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | ||||
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.category:VSCat | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.code | extensible | VitalSignshttp://hl7.org/fhir/ValueSet/observation-vitalsignresult from the FHIR Standard | ||||
Observation.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common from the FHIR Standard | ||||
Observation.value[x]:valueQuantity | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common from the FHIR Standard | ||||
Observation.value[x]:valueQuantity.comparator | required | QuantityComparatorhttp://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard | ||||
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard | ||||
Observation.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Observation.method | extensible | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methods from the FHIR Standard | ||||
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaning from the FHIR Standard | ||||
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliesto from the FHIR Standard | ||||
Observation.component.code | required | TWVitalSignshttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/vital-signs-tw | ||||
Observation.component.value[x] | required | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1 from the FHIR Standard | ||||
Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Observation | 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 | Observation | 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 | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Observation | 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() | |
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
vs-1 | error | Observation.effective[x] | if Observation.effective[x] is dateTime and has a value then that value shall be precise to the day : $this is dateTime implies $this.toString().length() >= 10 | |
vs-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present. : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
vs-3 | error | Observation.component | If there is no a value a data absent reason must be present : value.exists() or dataAbsentReason.exists() |
This structure is derived from TWCoreObservationVitalSigns
Summary
Mandatory: 3 elements
Must-Support: 2 elements
Fixed: 3 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron