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

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Resource Profile: 門診病歷-主觀描述_Subjective

此Profile用於描述門診病歷中病情摘要之主觀描述_Subjective [FMM1]

Usage:

• Use this Resource Profile: 門診病歷-Bundle
• Refer to this Resource Profile: 門診病歷-報告文件
• Examples for this Resource Profile: ClinicalImpression/PMR-Cli10

Formal Views of Profile Content

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

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from ClinicalImpression

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression		0..*	ClinicalImpression	A clinical assessment performed when planning treatments and management strategies for a patient
status	S	1..1	code	in-progress | completed | entered-in-error Fixed Value: completed
code	S	1..1	CodeableConcept	Kind of assessment performed
Slices for coding	S	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:code
coding:Subjective	S	1..*	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code	S	1..1	code	Symbol in syntax defined by the system Fixed Value: 61150-9
display	S	0..1	string	Representation defined by the system Fixed Value: Subjective
text	S	0..1	string	概念的文字表示法
subject	S	1..1	Reference(門診病歷-病人基本資料)	Patient or group assessed
note	S	1..*	Annotation	Comments made about the ClinicalImpression
text	S	1..1	markdown	關於此ClinicalImpression的附加資訊。[應填入於門診病歷主觀描述Subjective]
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression		0..*	ClinicalImpression	A clinical assessment performed when planning treatments and management strategies for a patient
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!SΣ	1..1	code	in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. Fixed Value: completed
code	SΣ	1..1	CodeableConcept	Kind of assessment performed Binding: (unbound) (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed.
Slices for coding	SΣ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:code
coding:Subjective	SΣ	1..*	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: 61150-9
display	SΣ	0..1	string	Representation defined by the system Fixed Value: Subjective
text	SΣ	0..1	string	概念的文字表示法
subject	SΣ	1..1	Reference(門診病歷-病人基本資料)	Patient or group assessed
note	S	1..*	Annotation	Comments made about the ClinicalImpression
text	SΣ	1..1	markdown	關於此ClinicalImpression的附加資訊。[應填入於門診病歷主觀描述Subjective]
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ClinicalImpression.status	required	Fixed Value: completed http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1 from the FHIR Standard
ClinicalImpression.code	example

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	ClinicalImpression	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	ClinicalImpression	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	ClinicalImpression	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	ClinicalImpression	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	ClinicalImpression	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression		0..*	ClinicalImpression	A clinical assessment performed when planning treatments and management strategies for a patient
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	Business identifier
status	?!SΣ	1..1	code	in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. Fixed Value: completed
statusReason		0..1	CodeableConcept	Reason for current status Binding: (unbound) (example): Codes identifying the reason for the current state of a clinical impression.
code	SΣ	1..1	CodeableConcept	Kind of assessment performed Binding: (unbound) (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	SΣ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:code
coding:Subjective	SΣ	1..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: 61150-9
display	SΣ	0..1	string	Representation defined by the system Fixed Value: Subjective
userSelected	Σ	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
description	Σ	0..1	string	Why/how the assessment was performed
subject	SΣ	1..1	Reference(門診病歷-病人基本資料)	Patient or group assessed
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
effective[x]	Σ	0..1		Time of assessment
effectiveDateTime			dateTime
effectivePeriod			Period
date	Σ	0..1	dateTime	When the assessment was documented
assessor	Σ	0..1	Reference(Practitioner | PractitionerRole)	The clinician performing the assessment
previous		0..1	Reference(ClinicalImpression)	Reference to last assessment
problem	Σ	0..*	Reference(Condition | AllergyIntolerance)	Relevant impressions of patient state
investigation		0..*	BackboneElement	One or more sets of investigations (signs, symptoms, etc.)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations.
item		0..*	Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media)	Record of a specific investigation
protocol		0..*	uri	Clinical Protocol followed
summary		0..1	string	Summary of the assessment
finding		0..*	BackboneElement	Possible or likely findings and diagnoses
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemCodeableConcept		0..1	CodeableConcept	What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.
itemReference		0..1	Reference(Condition | Observation | Media)	What was found
basis		0..1	string	Which investigations support finding
prognosisCodeableConcept		0..*	CodeableConcept	Estimate of likely outcome Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings.
prognosisReference		0..*	Reference(RiskAssessment)	RiskAssessment expressing likely outcome
supportingInfo		0..*	Reference(Resource)	Information supporting the clinical impression
note	S	1..*	Annotation	Comments made about the ClinicalImpression
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
author[x]	Σ	0..1		Individual responsible for the annotation
authorReference			Reference(Practitioner | Patient | RelatedPerson | Organization)
authorString			string
time	Σ	0..1	dateTime	When the annotation was made
text	SΣ	1..1	markdown	關於此ClinicalImpression的附加資訊。[應填入於門診病歷主觀描述Subjective]
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ClinicalImpression.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
ClinicalImpression.status	required	Fixed Value: completed http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1 from the FHIR Standard
ClinicalImpression.statusReason	example
ClinicalImpression.code	example
ClinicalImpression.investigation.code	example	InvestigationType http://hl7.org/fhir/ValueSet/investigation-sets from the FHIR Standard
ClinicalImpression.finding.itemCodeableConcept	example	Condition/Problem/DiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard
ClinicalImpression.prognosisCodeableConcept	example	ClinicalImpressionPrognosis http://hl7.org/fhir/ValueSet/clinicalimpression-prognosis from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	ClinicalImpression	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	ClinicalImpression	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	ClinicalImpression	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	ClinicalImpression	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	ClinicalImpression	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from ClinicalImpression

Summary

Mandatory: 6 elements
Must-Support: 11 elements
Fixed: 4 elements

Structures

This structure refers to these other structures:

• 門診病歷-病人基本資料 (https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRPatient)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of ClinicalImpression.code.coding

Differential View

This structure is derived from ClinicalImpression

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression		0..*	ClinicalImpression	A clinical assessment performed when planning treatments and management strategies for a patient
status	S	1..1	code	in-progress | completed | entered-in-error Fixed Value: completed
code	S	1..1	CodeableConcept	Kind of assessment performed
Slices for coding	S	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:code
coding:Subjective	S	1..*	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code	S	1..1	code	Symbol in syntax defined by the system Fixed Value: 61150-9
display	S	0..1	string	Representation defined by the system Fixed Value: Subjective
text	S	0..1	string	概念的文字表示法
subject	S	1..1	Reference(門診病歷-病人基本資料)	Patient or group assessed
note	S	1..*	Annotation	Comments made about the ClinicalImpression
text	S	1..1	markdown	關於此ClinicalImpression的附加資訊。[應填入於門診病歷主觀描述Subjective]
Documentation for this format

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression		0..*	ClinicalImpression	A clinical assessment performed when planning treatments and management strategies for a patient
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!SΣ	1..1	code	in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. Fixed Value: completed
code	SΣ	1..1	CodeableConcept	Kind of assessment performed Binding: (unbound) (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed.
Slices for coding	SΣ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:code
coding:Subjective	SΣ	1..*	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: 61150-9
display	SΣ	0..1	string	Representation defined by the system Fixed Value: Subjective
text	SΣ	0..1	string	概念的文字表示法
subject	SΣ	1..1	Reference(門診病歷-病人基本資料)	Patient or group assessed
note	S	1..*	Annotation	Comments made about the ClinicalImpression
text	SΣ	1..1	markdown	關於此ClinicalImpression的附加資訊。[應填入於門診病歷主觀描述Subjective]
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ClinicalImpression.status	required	Fixed Value: completed http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1 from the FHIR Standard
ClinicalImpression.code	example

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	ClinicalImpression	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	ClinicalImpression	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	ClinicalImpression	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	ClinicalImpression	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	ClinicalImpression	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression		0..*	ClinicalImpression	A clinical assessment performed when planning treatments and management strategies for a patient
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	Business identifier
status	?!SΣ	1..1	code	in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. Fixed Value: completed
statusReason		0..1	CodeableConcept	Reason for current status Binding: (unbound) (example): Codes identifying the reason for the current state of a clinical impression.
code	SΣ	1..1	CodeableConcept	Kind of assessment performed Binding: (unbound) (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	SΣ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:code
coding:Subjective	SΣ	1..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: 61150-9
display	SΣ	0..1	string	Representation defined by the system Fixed Value: Subjective
userSelected	Σ	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
description	Σ	0..1	string	Why/how the assessment was performed
subject	SΣ	1..1	Reference(門診病歷-病人基本資料)	Patient or group assessed
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
effective[x]	Σ	0..1		Time of assessment
effectiveDateTime			dateTime
effectivePeriod			Period
date	Σ	0..1	dateTime	When the assessment was documented
assessor	Σ	0..1	Reference(Practitioner | PractitionerRole)	The clinician performing the assessment
previous		0..1	Reference(ClinicalImpression)	Reference to last assessment
problem	Σ	0..*	Reference(Condition | AllergyIntolerance)	Relevant impressions of patient state
investigation		0..*	BackboneElement	One or more sets of investigations (signs, symptoms, etc.)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations.
item		0..*	Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media)	Record of a specific investigation
protocol		0..*	uri	Clinical Protocol followed
summary		0..1	string	Summary of the assessment
finding		0..*	BackboneElement	Possible or likely findings and diagnoses
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemCodeableConcept		0..1	CodeableConcept	What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.
itemReference		0..1	Reference(Condition | Observation | Media)	What was found
basis		0..1	string	Which investigations support finding
prognosisCodeableConcept		0..*	CodeableConcept	Estimate of likely outcome Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings.
prognosisReference		0..*	Reference(RiskAssessment)	RiskAssessment expressing likely outcome
supportingInfo		0..*	Reference(Resource)	Information supporting the clinical impression
note	S	1..*	Annotation	Comments made about the ClinicalImpression
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
author[x]	Σ	0..1		Individual responsible for the annotation
authorReference			Reference(Practitioner | Patient | RelatedPerson | Organization)
authorString			string
time	Σ	0..1	dateTime	When the annotation was made
text	SΣ	1..1	markdown	關於此ClinicalImpression的附加資訊。[應填入於門診病歷主觀描述Subjective]
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ClinicalImpression.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
ClinicalImpression.status	required	Fixed Value: completed http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1 from the FHIR Standard
ClinicalImpression.statusReason	example
ClinicalImpression.code	example
ClinicalImpression.investigation.code	example	InvestigationType http://hl7.org/fhir/ValueSet/investigation-sets from the FHIR Standard
ClinicalImpression.finding.itemCodeableConcept	example	Condition/Problem/DiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard
ClinicalImpression.prognosisCodeableConcept	example	ClinicalImpressionPrognosis http://hl7.org/fhir/ValueSet/clinicalimpression-prognosis from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	ClinicalImpression	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	ClinicalImpression	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	ClinicalImpression	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	ClinicalImpression	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	ClinicalImpression	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from ClinicalImpression

Summary

Mandatory: 6 elements
Must-Support: 11 elements
Fixed: 4 elements

Structures

This structure refers to these other structures:

• 門診病歷-病人基本資料 (https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRPatient)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of ClinicalImpression.code.coding

Other representations of profile: CSV, Excel, Schematron