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/ObservationDMSassumption | Version: 0.1.0 | |||
Active as of 2022-12-08 | Computable Name: DMSObservationAssumption |
此Profiles繼承於臺灣核心-檢驗檢查(TW Core Observation) ,並進一步用於描述出院病摘之住院臆斷
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from TWCoreObservation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 0..* | TWCoreObservation | 檢驗檢查,測量及簡單的判定。 | |
status | S | 1..1 | code | registered | preliminary | final | amended + Fixed Value: final |
code | S | 1..1 | CodeableConceptTW | 概念(concept)-參照一個專門術語或只是純文字。 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: 46241-6 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital admission Dx Reported | |
coding | 1..* | CodingTW | 由專門術語系統(terminology system)定義的代碼 | |
system | 1..1 | uri | 專門術語系統(terminology system)的識別 | |
code | 1..1 | code | 系統定義的語法之符號 | |
subject | 1..1 | Reference(出院病摘-病人基本資料) | 檢驗檢查有關的對象及(或)事物 | |
Slices for value[x] | 1..1 | string | 檢驗檢查的實際結果 Slice: Unordered, Open by type:$this | |
value[x]:valueString | 1..1 | string | 住院時的臆斷描述。[應填入至出院病摘住院臆斷Impression] | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | TWCoreObservation | 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 |
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 |
text | S | 0..1 | Narrative | Observation Resource之內容摘要以供人閱讀 |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): 檢驗檢查的狀態代碼;應填入ObservationStatus代碼表中的其中一個代碼。 Fixed Value: final |
category | 0..* | CodeableConceptTW | 檢驗檢查分類 Binding: ObservationCategoryCodes (preferred): 高層次的檢驗檢查分類;鼓勵使用ObservationCategoryCodes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。 | |
coding | S | 1..* | CodingTW | 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 |
code | SΣ | 1..1 | code | 系統定義的語法之符號 |
display | SΣ | 0..1 | string | 由系統定義的表示法 |
text | SΣ | 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: 生命體徵值集 (example): 應填入生命體徵值集代碼表中的其中一個代碼。 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: 46241-6 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital admission Dx Reported | |
coding | S | 1..* | CodingTW | 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 |
code | SΣ | 1..1 | code | 系統定義的語法之符號 |
display | SΣ | 0..1 | string | 由系統定義的表示法 |
text | SΣ | 0..1 | string | 概念的文字表示法 |
subject | Σ | 1..1 | Reference(出院病摘-病人基本資料) | 檢驗檢查有關的對象及(或)事物 |
performer | SΣ | 0..* | Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | PractitionerRole | CareTeam) | 誰負責這項檢驗檢查 |
Slices for value[x] | SΣC | 1..1 | string | 檢驗檢查的實際結果 Slice: Unordered, Closed by type:$this Binding: VitalSignsUnits (preferred): 用於記錄生命體徵的常用UCUM單元;應填入VitalSignsUnits代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 |
value[x]:valueString | SΣC | 1..1 | string | 住院時的臆斷描述。[應填入至出院病摘住院臆斷Impression] Binding: VitalSignsUnits (preferred): 用於記錄生命體徵的常用UCUM單元;應填入VitalSignsUnits代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 |
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DataAbsentReason代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 |
component | SΣ | 0..* | BackboneElement | 組成之(部分)檢驗檢查的檢驗結果 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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 (example): 代碼指明檢驗檢查的名稱;可參考生命體徵值集代碼表,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。 |
value[x] | SΣ | 0..1 | 組成之檢驗檢查的實際結果 Binding: VitalSignsUnits (preferred): 用於記錄生命體徵的常用UCUM單元。;應填入VitalSignsUnits代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 | |
valueQuantity | Quantity | |||
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DataAbsentReason代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Observation.status | required | Fixed Value: finalhttp://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.code | example | Pattern: LOINC Code 46241-6("Hospital admission Dx Reported")https://twcore.mohw.gov.tw/ig/twcore/ValueSet/vital-signs-tw | |
Observation.value[x] | preferred | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common from the FHIR Standard | |
Observation.value[x]:valueString | preferred | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common from the FHIR Standard | |
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | |
Observation.component.code | example | TWVitalSignshttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/vital-signs-tw | |
Observation.component.value[x] | preferred | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common 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() |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | TWCoreObservation | 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 |
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 | S | 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 | Additional content defined by implementations | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
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 | MedicationDispense | MedicationStatement | TW Core Procedure | Immunization | 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ObservationStatus代碼表中的其中一個代碼。 Fixed Value: final |
category | 0..* | CodeableConceptTW | 檢驗檢查分類 Binding: ObservationCategoryCodes (preferred): 高層次的檢驗檢查分類;鼓勵使用ObservationCategoryCodes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。 | |
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 |
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 |
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 |
display | SΣ | 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 | SΣ | 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: 生命體徵值集 (example): 應填入生命體徵值集代碼表中的其中一個代碼。 Required Pattern: At least the following |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
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: 46241-6 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital admission Dx Reported | |
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 |
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 |
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 |
display | SΣ | 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 | SΣ | 0..1 | string | 概念的文字表示法 |
subject | Σ | 1..1 | Reference(出院病摘-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(TW Core Encounter) | 檢驗檢查是哪一次就醫時執行的 |
effective[x] | Σ | 0..1 | 檢驗檢查執行日期或時間區間 | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
effectiveTiming | Timing | |||
effectiveInstant | instant | |||
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 | PractitionerRole | CareTeam) | 誰負責這項檢驗檢查 |
Slices for value[x] | SΣC | 1..1 | string | 檢驗檢查的實際結果 Slice: Unordered, Closed by type:$this Binding: VitalSignsUnits (preferred): 用於記錄生命體徵的常用UCUM單元;應填入VitalSignsUnits代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 |
value[x]:valueString | SΣC | 1..1 | string | 住院時的臆斷描述。[應填入至出院病摘住院臆斷Impression] Binding: VitalSignsUnits (preferred): 用於記錄生命體徵的常用UCUM單元;應填入VitalSignsUnits代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 |
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DataAbsentReason代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 |
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ObservationInterpretationCodes代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 | |
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 (example): 代碼說明解剖學位置,可能包含側邊;可參考SNOMEDCTBodyStructures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。 | |
method | 0..1 | CodeableConceptTW | 此檢驗檢查使用何種方法完成 Binding: ObservationMethods (example): 檢驗檢查的方法;可參考ObservationMethods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。 | |
specimen | 0..1 | Reference(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 | Additional content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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ObservationReferenceRangeMeaningCodes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。 | |
appliesTo | 0..* | CodeableConceptTW | 參考範圍值的人群 Binding: ObservationReferenceRangeAppliesToCodes (example): 用以指明參考範圍值適用的人群之代碼;可參考ObservationReferenceRangeAppliesToCodes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(Observation | QuestionnaireResponse | MolecularSequence) | 屬於此組檢驗檢查的相關Resource |
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | 檢驗檢查源自哪些相關測量 |
component | SΣ | 0..* | BackboneElement | 組成之(部分)檢驗檢查的檢驗結果 |
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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 (example): 代碼指明檢驗檢查的名稱;可參考生命體徵值集代碼表,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。 |
value[x] | SΣ | 0..1 | 組成之檢驗檢查的實際結果 Binding: VitalSignsUnits (preferred): 用於記錄生命體徵的常用UCUM單元。;應填入VitalSignsUnits代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 | |
valueQuantity | Quantity | |||
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DataAbsentReason代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 |
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ObservationInterpretationCodes代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 | |
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 / Code | URI |
Observation.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard | |
Observation.status | required | Fixed Value: finalhttp://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.code | example | Pattern: LOINC Code 46241-6("Hospital admission Dx Reported")https://twcore.mohw.gov.tw/ig/twcore/ValueSet/vital-signs-tw | |
Observation.value[x] | preferred | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common from the FHIR Standard | |
Observation.value[x]:valueString | preferred | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common 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 | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | |
Observation.method | example | 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 | example | TWVitalSignshttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/vital-signs-tw | |
Observation.component.value[x] | preferred | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common 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() |
This structure is derived from TWCoreObservation
Summary
Mandatory: 5 elements
Must-Support: 2 elements
Fixed: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from TWCoreObservation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 0..* | TWCoreObservation | 檢驗檢查,測量及簡單的判定。 | |
status | S | 1..1 | code | registered | preliminary | final | amended + Fixed Value: final |
code | S | 1..1 | CodeableConceptTW | 概念(concept)-參照一個專門術語或只是純文字。 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: 46241-6 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital admission Dx Reported | |
coding | 1..* | CodingTW | 由專門術語系統(terminology system)定義的代碼 | |
system | 1..1 | uri | 專門術語系統(terminology system)的識別 | |
code | 1..1 | code | 系統定義的語法之符號 | |
subject | 1..1 | Reference(出院病摘-病人基本資料) | 檢驗檢查有關的對象及(或)事物 | |
Slices for value[x] | 1..1 | string | 檢驗檢查的實際結果 Slice: Unordered, Open by type:$this | |
value[x]:valueString | 1..1 | string | 住院時的臆斷描述。[應填入至出院病摘住院臆斷Impression] | |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | TWCoreObservation | 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 |
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 |
text | S | 0..1 | Narrative | Observation Resource之內容摘要以供人閱讀 |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): 檢驗檢查的狀態代碼;應填入ObservationStatus代碼表中的其中一個代碼。 Fixed Value: final |
category | 0..* | CodeableConceptTW | 檢驗檢查分類 Binding: ObservationCategoryCodes (preferred): 高層次的檢驗檢查分類;鼓勵使用ObservationCategoryCodes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。 | |
coding | S | 1..* | CodingTW | 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 |
code | SΣ | 1..1 | code | 系統定義的語法之符號 |
display | SΣ | 0..1 | string | 由系統定義的表示法 |
text | SΣ | 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: 生命體徵值集 (example): 應填入生命體徵值集代碼表中的其中一個代碼。 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: 46241-6 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital admission Dx Reported | |
coding | S | 1..* | CodingTW | 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 |
code | SΣ | 1..1 | code | 系統定義的語法之符號 |
display | SΣ | 0..1 | string | 由系統定義的表示法 |
text | SΣ | 0..1 | string | 概念的文字表示法 |
subject | Σ | 1..1 | Reference(出院病摘-病人基本資料) | 檢驗檢查有關的對象及(或)事物 |
performer | SΣ | 0..* | Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | PractitionerRole | CareTeam) | 誰負責這項檢驗檢查 |
Slices for value[x] | SΣC | 1..1 | string | 檢驗檢查的實際結果 Slice: Unordered, Closed by type:$this Binding: VitalSignsUnits (preferred): 用於記錄生命體徵的常用UCUM單元;應填入VitalSignsUnits代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 |
value[x]:valueString | SΣC | 1..1 | string | 住院時的臆斷描述。[應填入至出院病摘住院臆斷Impression] Binding: VitalSignsUnits (preferred): 用於記錄生命體徵的常用UCUM單元;應填入VitalSignsUnits代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 |
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DataAbsentReason代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 |
component | SΣ | 0..* | BackboneElement | 組成之(部分)檢驗檢查的檢驗結果 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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 (example): 代碼指明檢驗檢查的名稱;可參考生命體徵值集代碼表,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。 |
value[x] | SΣ | 0..1 | 組成之檢驗檢查的實際結果 Binding: VitalSignsUnits (preferred): 用於記錄生命體徵的常用UCUM單元。;應填入VitalSignsUnits代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 | |
valueQuantity | Quantity | |||
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DataAbsentReason代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Observation.status | required | Fixed Value: finalhttp://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.code | example | Pattern: LOINC Code 46241-6("Hospital admission Dx Reported")https://twcore.mohw.gov.tw/ig/twcore/ValueSet/vital-signs-tw | |
Observation.value[x] | preferred | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common from the FHIR Standard | |
Observation.value[x]:valueString | preferred | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common from the FHIR Standard | |
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | |
Observation.component.code | example | TWVitalSignshttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/vital-signs-tw | |
Observation.component.value[x] | preferred | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common 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() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | TWCoreObservation | 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 |
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 | S | 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 | Additional content defined by implementations | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
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 | MedicationDispense | MedicationStatement | TW Core Procedure | Immunization | 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ObservationStatus代碼表中的其中一個代碼。 Fixed Value: final |
category | 0..* | CodeableConceptTW | 檢驗檢查分類 Binding: ObservationCategoryCodes (preferred): 高層次的檢驗檢查分類;鼓勵使用ObservationCategoryCodes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。 | |
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 |
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 |
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 |
display | SΣ | 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 | SΣ | 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: 生命體徵值集 (example): 應填入生命體徵值集代碼表中的其中一個代碼。 Required Pattern: At least the following |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
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: 46241-6 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital admission Dx Reported | |
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 |
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 |
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 |
display | SΣ | 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 | SΣ | 0..1 | string | 概念的文字表示法 |
subject | Σ | 1..1 | Reference(出院病摘-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(TW Core Encounter) | 檢驗檢查是哪一次就醫時執行的 |
effective[x] | Σ | 0..1 | 檢驗檢查執行日期或時間區間 | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
effectiveTiming | Timing | |||
effectiveInstant | instant | |||
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 | PractitionerRole | CareTeam) | 誰負責這項檢驗檢查 |
Slices for value[x] | SΣC | 1..1 | string | 檢驗檢查的實際結果 Slice: Unordered, Closed by type:$this Binding: VitalSignsUnits (preferred): 用於記錄生命體徵的常用UCUM單元;應填入VitalSignsUnits代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 |
value[x]:valueString | SΣC | 1..1 | string | 住院時的臆斷描述。[應填入至出院病摘住院臆斷Impression] Binding: VitalSignsUnits (preferred): 用於記錄生命體徵的常用UCUM單元;應填入VitalSignsUnits代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 |
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DataAbsentReason代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 |
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ObservationInterpretationCodes代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 | |
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 (example): 代碼說明解剖學位置,可能包含側邊;可參考SNOMEDCTBodyStructures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。 | |
method | 0..1 | CodeableConceptTW | 此檢驗檢查使用何種方法完成 Binding: ObservationMethods (example): 檢驗檢查的方法;可參考ObservationMethods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。 | |
specimen | 0..1 | Reference(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 | Additional content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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ObservationReferenceRangeMeaningCodes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。 | |
appliesTo | 0..* | CodeableConceptTW | 參考範圍值的人群 Binding: ObservationReferenceRangeAppliesToCodes (example): 用以指明參考範圍值適用的人群之代碼;可參考ObservationReferenceRangeAppliesToCodes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(Observation | QuestionnaireResponse | MolecularSequence) | 屬於此組檢驗檢查的相關Resource |
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | 檢驗檢查源自哪些相關測量 |
component | SΣ | 0..* | BackboneElement | 組成之(部分)檢驗檢查的檢驗結果 |
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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 (example): 代碼指明檢驗檢查的名稱;可參考生命體徵值集代碼表,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。 |
value[x] | SΣ | 0..1 | 組成之檢驗檢查的實際結果 Binding: VitalSignsUnits (preferred): 用於記錄生命體徵的常用UCUM單元。;應填入VitalSignsUnits代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 | |
valueQuantity | Quantity | |||
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DataAbsentReason代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 |
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ObservationInterpretationCodes代碼表中適合的代碼,確定無適合的代碼才可以使用其他代碼中的代碼來表示。 | |
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 / Code | URI |
Observation.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard | |
Observation.status | required | Fixed Value: finalhttp://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.code | example | Pattern: LOINC Code 46241-6("Hospital admission Dx Reported")https://twcore.mohw.gov.tw/ig/twcore/ValueSet/vital-signs-tw | |
Observation.value[x] | preferred | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common from the FHIR Standard | |
Observation.value[x]:valueString | preferred | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common 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 | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | |
Observation.method | example | 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 | example | TWVitalSignshttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/vital-signs-tw | |
Observation.component.value[x] | preferred | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common 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() |
This structure is derived from TWCoreObservation
Summary
Mandatory: 5 elements
Must-Support: 2 elements
Fixed: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron