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/PMRModel | Version: 0.1.0 | |||
Draft as of 2024-08-23 | Computable Name: PMRModel |
用於描述門診病歷邏輯模型
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Element
Id | Grade | Path(s) | Details | Requirements |
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 |
---|---|---|---|---|
PMRModel | 0..* | Element | Elements defined in Ancestors:@id, extension 門診病歷邏輯模型 Instances of this logical model are not marked to be the target of a Reference | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
hospital | 1..1 | BackboneElement | 醫事機構 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
hospitalId | 1..1 | Identifier | 醫事機構代碼 | |
hospitalName | 1..1 | string | 醫事機構名稱 | |
patientInformation | 1..1 | BackboneElement | 病人基本資料 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
personalIDNumber | 1..1 | Identifier | 身分證號 | |
chartNo | 1..1 | Identifier | 病歷號碼 | |
name | 1..1 | HumanName | 病人性名 | |
gender | 1..1 | code | 性別 | |
birthDate | 1..1 | date | 出生日期 | |
bloodType | 1..1 | CodeableConcept | 血型 | |
rhType | 1..1 | CodeableConcept | D抗原性 | |
majorIllness | 1..* | CodeableConcept | 重大傷病 | |
historyOfAllergies | 1..* | CodeableConcept | 過敏史 | |
age | 1..1 | Age | 就診年齡 | |
occupation | 0..1 | CodeableConcept | 職業 | |
identityType | 1..1 | CodeableConcept | 就醫身分別 | |
opdDate | 1..1 | dateTime | 門診日期 | |
department | 1..1 | CodeableConcept | 科別 | |
diagnosis | 1..* | BackboneElement | 診斷 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
icdCode | 1..1 | code | 國際疾病分類代碼 | |
icdName | 1..1 | string | 國際疾病分類名稱 | |
note | 0..1 | Annotation | 註記 | |
conditionSummary | 1..1 | BackboneElement | 病情摘要 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
subjective | 1..1 | Annotation | 主觀描述 | |
objective | 1..1 | Annotation | 客觀描述 | |
assessment | 1..1 | Annotation | 評估 | |
procedure | 1..* | BackboneElement | 處置項目 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
item | 1..1 | Identifier | 項次 | |
procedureCode | 1..1 | code | 處置代碼 | |
procedureName | 1..1 | string | 處置名稱 | |
frequency | 0..1 | CodeableConcept | 頻率 | |
amount | 1..1 | CodeableConcept | 數量 | |
units | 1..1 | CodeableConcept | 單位 | |
part | 0..* | CodeableConcept | 部位 | |
note | 0..1 | Annotation | 註記 | |
selfPaynote | 0..1 | Annotation | 自費註記 | |
prescriptionContent | 1..* | BackboneElement | 處方內容 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
item | 1..1 | Identifier | 項次 | |
typesofPrescription | 1..1 | CodeableConcept | 處方箋種類註記 | |
drugCode | 1..1 | code | 藥品代碼 | |
brandName | 1..1 | string | 藥品商品名稱 | |
genericName | 1..1 | string | 學名 | |
dosageForm | 1..1 | string | 劑型 | |
dose | 1..1 | decimal | 劑量 | |
doseUnits | 1..1 | string | 劑量單位 | |
frequency | 1..1 | CodeableConcept | 頻率 | |
routeofAdministration | 1..1 | CodeableConcept | 給藥途徑 | |
medicationDays | 1..1 | decimal | 給藥日數 | |
totalAmount | 1..1 | decimal | 給藥總量 | |
totalUnits | 1..1 | string | 給藥總量單位 | |
actualAmount | 0..1 | decimal | 實際給藥總量 | |
actualUnits | 0..1 | string | 實際給藥總量單位 | |
powdered | 1..1 | code | 磨粉註記 | |
note | 0..1 | Annotation | 註記 | |
selfPaynote | 0..1 | Annotation | 自費註記 | |
familyTree | 0..* | BackboneElement | 家族圖譜 | |
opdImage | 0..* | BackboneElement | 門診圖像 | |
physicianName | 1..1 | HumanName | 醫師姓名 | |
Documentation for this format |
Id | Grade | Path(s) | Details | Requirements |
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 Element
Differential View
This structure is derived from Element
Key Elements View
Id | Grade | Path(s) | Details | Requirements |
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 |
---|---|---|---|---|
PMRModel | 0..* | Element | Elements defined in Ancestors:@id, extension 門診病歷邏輯模型 Instances of this logical model are not marked to be the target of a Reference | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
hospital | 1..1 | BackboneElement | 醫事機構 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
hospitalId | 1..1 | Identifier | 醫事機構代碼 | |
hospitalName | 1..1 | string | 醫事機構名稱 | |
patientInformation | 1..1 | BackboneElement | 病人基本資料 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
personalIDNumber | 1..1 | Identifier | 身分證號 | |
chartNo | 1..1 | Identifier | 病歷號碼 | |
name | 1..1 | HumanName | 病人性名 | |
gender | 1..1 | code | 性別 | |
birthDate | 1..1 | date | 出生日期 | |
bloodType | 1..1 | CodeableConcept | 血型 | |
rhType | 1..1 | CodeableConcept | D抗原性 | |
majorIllness | 1..* | CodeableConcept | 重大傷病 | |
historyOfAllergies | 1..* | CodeableConcept | 過敏史 | |
age | 1..1 | Age | 就診年齡 | |
occupation | 0..1 | CodeableConcept | 職業 | |
identityType | 1..1 | CodeableConcept | 就醫身分別 | |
opdDate | 1..1 | dateTime | 門診日期 | |
department | 1..1 | CodeableConcept | 科別 | |
diagnosis | 1..* | BackboneElement | 診斷 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
icdCode | 1..1 | code | 國際疾病分類代碼 | |
icdName | 1..1 | string | 國際疾病分類名稱 | |
note | 0..1 | Annotation | 註記 | |
conditionSummary | 1..1 | BackboneElement | 病情摘要 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
subjective | 1..1 | Annotation | 主觀描述 | |
objective | 1..1 | Annotation | 客觀描述 | |
assessment | 1..1 | Annotation | 評估 | |
procedure | 1..* | BackboneElement | 處置項目 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
item | 1..1 | Identifier | 項次 | |
procedureCode | 1..1 | code | 處置代碼 | |
procedureName | 1..1 | string | 處置名稱 | |
frequency | 0..1 | CodeableConcept | 頻率 | |
amount | 1..1 | CodeableConcept | 數量 | |
units | 1..1 | CodeableConcept | 單位 | |
part | 0..* | CodeableConcept | 部位 | |
note | 0..1 | Annotation | 註記 | |
selfPaynote | 0..1 | Annotation | 自費註記 | |
prescriptionContent | 1..* | BackboneElement | 處方內容 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
item | 1..1 | Identifier | 項次 | |
typesofPrescription | 1..1 | CodeableConcept | 處方箋種類註記 | |
drugCode | 1..1 | code | 藥品代碼 | |
brandName | 1..1 | string | 藥品商品名稱 | |
genericName | 1..1 | string | 學名 | |
dosageForm | 1..1 | string | 劑型 | |
dose | 1..1 | decimal | 劑量 | |
doseUnits | 1..1 | string | 劑量單位 | |
frequency | 1..1 | CodeableConcept | 頻率 | |
routeofAdministration | 1..1 | CodeableConcept | 給藥途徑 | |
medicationDays | 1..1 | decimal | 給藥日數 | |
totalAmount | 1..1 | decimal | 給藥總量 | |
totalUnits | 1..1 | string | 給藥總量單位 | |
actualAmount | 0..1 | decimal | 實際給藥總量 | |
actualUnits | 0..1 | string | 實際給藥總量單位 | |
powdered | 1..1 | code | 磨粉註記 | |
note | 0..1 | Annotation | 註記 | |
selfPaynote | 0..1 | Annotation | 自費註記 | |
familyTree | 0..* | BackboneElement | 家族圖譜 | |
opdImage | 0..* | BackboneElement | 門診圖像 | |
physicianName | 1..1 | HumanName | 醫師姓名 | |
Documentation for this format |
Id | Grade | Path(s) | Details | Requirements |
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 Element