電子病歷交換單張實作指引(EMR-IG)
0.1.0 - ci-build

This page is part of the 電子病歷交換單張實作指引(EMR-IG) (v0.1.0: Releases) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: PMRProcedure - Detailed Descriptions

Draft as of 2024-08-23

Definitions for the PMRProcedure resource profile.

Guidance on how to interpret the contents of this table can be found here

0. Procedure
2. Procedure.identifier
Short此處置/手術的外部識別碼。[應填入門診病歷項次Item]
NoteThis is a business identifier, not a resource identifier (see discussion)
Control1..?
Must Supporttrue
4. Procedure.identifier.system
Must Supporttrue
6. Procedure.identifier.value
Control1..?
Must Supporttrue
8. Procedure.status
Fixed Valuecompleted
10. Procedure.code
Definition

所進行的特定處置。如果不能對處置的確切種類進行編碼,則使用文字(例如:「腹腔鏡闌尾切除術」)。 處置代碼Procedure Code對應至Coding.code 處置名稱Procedure Name對應至Coding.display

Short處置的識別碼。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。[應填入於門診病歷處置代碼Procedure Code與處置名稱Procedure Name]
12. Procedure.subject
Short誰有此病情、問題或診斷?
TypeReference(門診病歷-病人基本資料)
14. Procedure.bodySite
Short目標身體部位。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。[應填入於門診病歷部位Part]
16. Procedure.followUp
Short追蹤說明。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。[應填入於門診病歷數量Amount、頻率Frequency與單位Units]
Control3..?
Must Supporttrue
18. Procedure.note
Must Supporttrue
20. Procedure.note.text
ShortThe annotation - text content (as markdown)。[應填入於門診病歷註記或自費註記 Note/Self-pay note]
Must Supporttrue

Guidance on how to interpret the contents of this table can be found here

0. Procedure
Definition

正在或曾經對病人執行的動作。這可以是像手術這樣的身體介入,也可以是像長照服務、諮詢或催眠療法這樣的非侵入性介入。HL7 FHIR官網另有提到的例子包括例如包括診斷處置/手術、內視鏡處置/手術、活體組織切片、諮詢、物理治療、個人支持服務、日照服務、非緊急運輸、改善家居設施、健身活動等。處置/手術可以由醫護人員、服務提供人員、朋友或親屬或在某些情況下由病人自己執行。


An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy.

Short正在或曾經對病人執行的動作An action that is being or was performed on a patient
Control0..*
Is Modifierfalse
Summaryfalse
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. Procedure.implicitRules
Definition

構建resource時遵循的一系列規則的參照,在處理內容時必須理解這些規則。通常這是對IG所定義之特殊規則及其他profiles的參照。


A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Short創建此內容所依據的一組規則A set of rules under which this content was created
Comments

宣告這套規則限制了內容只能被有限的交易夥伴所理解。這從本質上限制了資料的長期有用性。然而,現有的健康生態體系高度分裂,還沒有準備好以普遍可計算的方式定義、收集和交換資料。只要有可能,實作者和/或規範編寫者應該避免使用這個資料項目。通常在使用時,此URL是對IG的參照,此IG將這些特殊規則與其他profiles、value sets等一起定義為其敘述的一部分。


Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. Procedure.modifierExtension
Definition

可以用來表示不屬於此resource的基本定義的額外資訊,並修改包含它所內嵌(contained)的資料項目的理解和/或對包含資料項目之後續使用的理解。通常修飾用的資料項目提供否定或限定的資訊。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。雖然任何實作者都可以定義一個擴充,但在定義擴充時 必須(SHALL) 滿足一組要求。處理resource的應用程式需要檢查修飾用的擴充資料項目。
修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。


May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Short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。Extensions that cannot be ignored
Comments

任何應用程式、專案或標準使用擴充時,都不應該帶有任何負面的聯想。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。


There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

修飾用的資料項目擴充允許將不能安全地忽略的擴充,與絕大多數可以安全地忽略的擴充明確區分開來。這樣做有助於促進可互操作性,因為無需禁止實作者使用擴充,想要瞭解更多資訊,請參見[修飾用的資料項目擴充之定義](http://hl7.org/fhir/R4/extensibility.html#modifierExtension)。


Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
6. Procedure.identifier
Definition

由執行者或其他系統指定給此處置/手術的業務用識別碼,即使此resource作更新及在伺服器之間的傳遞,此識別碼仍保持不變。


Business identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and is propagated from server to server.

Short此處置/手術的外部識別碼。[應填入門診病歷項次Item]External Identifiers for this procedure
Comments

這是一個業務識別碼,不是一個resource識別碼(詳見討論)。最好的做法是該識別碼只出現在單個resource實例上,但是業務實務有可能會規定可以在多個resource實例中具有相同識別碼—甚至可能具有不同的resource型例。例如:多個 「Patient(病人)」和 「Person(個人)」resource實例可能共用同一個社會保險號碼。


This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and Person resource instances might share the same social insurance number.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control10..*
TypeIdentifier
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

允許識別各參與系統所知的此處置/手術資訊,並在各伺服器之間保持一致的方式。


Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. Procedure.identifier.use
Definition

The purpose of this identifier.

Shortusual | official | temp | secondary | old (If known)
Comments

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Control0..1
BindingThe codes SHALL be taken from IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1
(required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1)

Identifies the purpose for this identifier, if known .

Typecode
Is Modifiertrue because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. Procedure.identifier.system
Definition

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

ShortThe namespace for the identifier value
Comments

Identifier.system is always case sensitive.

Control0..1
Typeuri
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

Example<br/><b>General</b>:http://www.acme.com/identifiers/patient
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. Procedure.identifier.value
Definition

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

ShortThe value that is unique
Comments

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Control10..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Example<br/><b>General</b>:123456
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
14. Procedure.status
Definition

一個指定處置/手術當前狀態的代碼。一般來說,它是進行中或完成的狀態。


A code specifying the state of the procedure. Generally, this will be the in-progress or completed state.

Shortpreparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknownpreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Comments

「未知」代碼不能用來表達其他狀態。當其中一個狀態適用時但編輯系統不知道此處置/手術的當前狀態,應該使用「未知」代碼。

此資料項目被標記為修飾用,因為狀態包含標記resource當前無效的代碼。


The "unknown" code is not to be used to convey other statuses. The "unknown" code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Control1..1
BindingThe codes SHALL be taken from EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1
(required to http://hl7.org/fhir/ValueSet/event-status|4.0.1)

應填入所綁定值集中的其中一個代碼


A code specifying the state of the procedure.

Typecode
Is Modifiertrue because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Fixed Valuecompleted
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
16. Procedure.code
Definition

所進行的特定處置。如果不能對處置的確切種類進行編碼,則使用文字(例如:「腹腔鏡闌尾切除術」)。 處置代碼Procedure Code對應至Coding.code 處置名稱Procedure Name對應至Coding.display


The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").

Short處置的識別碼。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。[應填入於門診病歷處置代碼Procedure Code與處置名稱Procedure Name]Identification of the procedure
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control10..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code
(example to http://hl7.org/fhir/ValueSet/procedure-code)

A code to identify a specific procedure .

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Requirements

0..1主要僅用於解釋敘述性的resource。


0..1 to account for primarily narrative only resources.

Alternate Namestype
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
18. Procedure.code.coding
Definition

由專門術語系統(terminology system)所定義之代碼的參照。


A reference to a code defined by a terminology system.

Short由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。Code defined by a terminology system
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Control0..*
This element is affected by the following invariants: ele-1
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼


Allows for alternative encodings within a code system, and translations to other code systems.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Procedure.code.coding. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • pattern @ $this
  • 20. Procedure.code.coding:icd10-pcs-2021
    Slice Nameicd10-pcs-2021
    Definition

    由專門術語系統(terminology system)所定義之代碼的參照。


    A reference to a code defined by a terminology system.

    Short此為臺灣衛生福利部中央健康保險署(NHI)維護之2021年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。Code defined by a terminology system
    Comments

    代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


    Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

    Control0..1*
    This element is affected by the following invariants: ele-1
    BindingThe codes SHALL be taken from For codes, see 臺灣健保署2021年中文版ICD-10-PCS值集
    (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw)

    處置/手術的識別;應填入所綁定值集中的其中一個代碼。

    TypeCoding(TW Coding)
    Is Modifierfalse
    Must Supporttrue
    Requirements

    允許使用者在不知道識別碼系統的情況下利用識別碼


    Allows for alternative encodings within a code system, and translations to other code systems.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    22. Procedure.code.coding:icd10-pcs-2014
    Slice Nameicd10-pcs-2014
    Definition

    由專門術語系統(terminology system)所定義之代碼的參照。


    A reference to a code defined by a terminology system.

    Short此為臺灣衛生福利部中央健康保險署(NHI)維護之2014年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。Code defined by a terminology system
    Comments

    代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


    Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

    Control0..1*
    This element is affected by the following invariants: ele-1
    BindingThe codes SHALL be taken from For codes, see 臺灣健保署2014年中文版ICD-10-PCS值集
    (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2014-tw)

    處置/手術的識別;應填入所綁定值集中的其中一個代碼。

    TypeCoding(TW Coding)
    Is Modifierfalse
    Must Supporttrue
    Requirements

    允許使用者在不知道識別碼系統的情況下利用識別碼


    Allows for alternative encodings within a code system, and translations to other code systems.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    24. Procedure.code.coding:icd9-cm-2001
    Slice Nameicd9-cm-2001
    Definition

    由專門術語系統(terminology system)所定義之代碼的參照


    A reference to a code defined by a terminology system.

    Short由專門術語系統(terminology system)定義的代碼Code defined by a terminology system
    Comments

    代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,例如:SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


    Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

    Control0..1*
    This element is affected by the following invariants: ele-1
    BindingThe codes SHALL be taken from For codes, see 臺灣健保署2001年中文版ICD-9-CM值集
    (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw)
    TypeCoding(TW Coding)
    Is Modifierfalse
    Must Supporttrue
    Requirements

    允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。


    Allows for alternative encodings within a code system, and translations to other code systems.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    26. Procedure.code.coding:medical-service-payment
    Slice Namemedical-service-payment
    Definition

    由專門術語系統(terminology system)所定義之代碼的參照。


    A reference to a code defined by a terminology system.

    Short此為臺灣衛生福利部中央健康保險署(NHI)維護之醫療服務給付項目,主要針對申報使用,可免費使用,可依情境選用此代碼。Code defined by a terminology system
    Comments

    代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


    Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

    Control0..1*
    This element is affected by the following invariants: ele-1
    BindingThe codes SHALL be taken from For codes, see 臺灣衛福部統計處藥品使用頻率值集
    (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/medication-frequency-tw)

    處置/手術的識別;應填入所綁定值集中的其中一個代碼。

    TypeCoding(TW Coding)
    Is Modifierfalse
    Must Supporttrue
    Requirements

    允許使用者在不知道識別碼系統的情況下利用識別碼


    Allows for alternative encodings within a code system, and translations to other code systems.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    28. Procedure.code.coding:sct-procedures
    Slice Namesct-procedures
    Definition

    由專門術語系統(terminology system)所定義之代碼的參照。


    A reference to a code defined by a terminology system.

    Short此為SNOMED CT處置/手術代碼,若機構已有購買相關授權,亦可使用。Code defined by a terminology system
    Comments

    代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


    Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

    Control0..1*
    This element is affected by the following invariants: ele-1
    BindingThe codes SHALL be taken from For codes, see ProcedureCodes(SNOMEDCT)
    (required to http://hl7.org/fhir/ValueSet/procedure-code)

    處置/手術的識別;應填入所綁定值集中的其中一個代碼。

    TypeCoding(TW Coding)
    Is Modifierfalse
    Must Supporttrue
    Requirements

    允許使用者在不知道識別碼系統的情況下利用識別碼


    Allows for alternative encodings within a code system, and translations to other code systems.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    30. Procedure.code.text
    Definition

    輸入資料的使用者所見/所選/所說的人類可讀文字表述,和(或)其代表使用者的預期含義。


    A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

    Short概念的文字表示法Plain text representation of the concept
    Comments

    很多時候,此文字表述與其中一個代碼的顯示名稱相同。


    Very often the text is the same as a displayName of one of the codings.

    Control0..1
    Typestring
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Requirements

    專門術語中的代碼並不總是能捕捉人類使用的細微差別的正確意義,或者根本就沒有合適的代碼;這些情況下,文字表述被用來捕捉來源的全部意義。


    The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    32. Procedure.subject
    Definition

    進行處置/手術的病人、動物或實體集合(例如:特定的一群人)。


    The person, animal or group on which the procedure was performed.

    Short誰有此病情、問題或診斷?Who the procedure was performed on
    Control1..1
    TypeReference(門診病歷-病人基本資料, Patient, Group)
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Alternate Namespatient
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    34. Procedure.performed[x]
    Definition

    進行處置/手術的估計或實際日期、日期時間、時間區間或年齡。允許一個時間區間來支持跨越一個日期以上的複雜處置/手術,也允許捕捉處置/手術的執行時間長度。


    Estimated or actual date, date-time, period, or age when the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured.

    Short此處置/手術何時執行的?When the procedure was performed
    Comments

    年齡一般用於病人報告其進行手術的年齡,像是20到25歲時。 dateTime支援一定的精度範圍,因為有些處置/手術被報告為過去的處置/手術,可能沒有毫秒的精度,而其他在就醫期間執行和記錄的處置/手術可能有更精確的UTC時間戳記和時區。


    Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone.

    Control0..1
    TypeChoice of: dateTime, Period, string, Age, Range
    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Must Support TypesdateTime
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    36. Procedure.asserter
    Definition

    提出此處置/手術說明的人


    Individual who is making the procedure statement.

    Short聲稱有此處置/手術的人Person who asserts this procedure
    Control0..1
    TypeReference(TW Core Patient, RelatedPerson, TW Core Practitioner, TW Core PractitionerRole, Patient, Practitioner, PractitionerRole)
    Is Modifierfalse
    Must Supporttrue
    Must Support TypesNo must-support rules about the choice of types/profiles
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    38. Procedure.performer
    Definition

    限於「真正的」人而不是設備


    Limited to "real" people rather than equipment.

    Short執行處置/手術的人員The people who performed the procedure
    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    40. Procedure.performer.modifierExtension
    Definition

    可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。 修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。


    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    Short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。Extensions that cannot be ignored even if unrecognized
    Comments

    無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。


    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
    Summarytrue
    Requirements

    修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互通性。更多訊息,請參見修飾用的資料項目擴充之定義


    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    42. Procedure.performer.actor
    Definition

    參與處置/手術的健康照護服務提供者


    The practitioner who was involved in the procedure.

    Short參照至健康照護服務提供者The reference to the practitioner
    Control1..1
    TypeReference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, TW Core Patient, RelatedPerson, Device, Practitioner, PractitionerRole, Organization, Patient)
    Is Modifierfalse
    Must Supporttrue
    Must Support TypesNo must-support rules about the choice of types/profiles
    Summarytrue
    Requirements

    一個參照至裝置(Device)的使用案例,例如:心律調整器。


    A reference to Device supports use cases, such as pacemakers.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    44. Procedure.performer.onBehalfOf
    Definition

    此裝置或健康照護服務提供者所代表的機構


    The organization the device or practitioner was acting on behalf of.

    Short此裝置(Device)或健康照護服務提供者所屬機構(Organization)Organization the device or practitioner was acting for
    Control0..1
    TypeReference(TW Core Organization, Organization)
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Requirements

    健康照護服務提供者和裝置可以與多個機構相關聯,此資料項目表明他們在執行行動時代表哪個機構。


    Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    46. Procedure.bodySite
    Definition

    詳細和結構化的解剖學位置資訊。允許多個位置—例如:一個病灶的多個活體組織切片。


    Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.

    Short目標身體部位。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。[應填入於門診病歷部位Part]Target body sites
    Comments

    如果案例需要BodySite resource的屬性(例如:識別和各別追蹤),那麼就使用標準擴充[procedure-targetbodystructure](擴充-procedure-targetbodystructure.html)。


    If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension procedure-targetbodystructure.

    Control0..*
    This element is affected by the following invariants: ele-1
    BindingUnless not suitable, these codes SHALL be taken from For example codes, see SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site
    (extensible to http://hl7.org/fhir/ValueSet/body-site)

    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。


    Codes describing anatomical locations. May include laterality.

    TypeCodeableConcept(TW CodeableConcept)
    Is Modifierfalse
    Must Supporttrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    48. Procedure.followUp
    Definition

    如果該處置/手術需要特定的後續行動—例如拆除縫線。 後續行動可以表現為一個簡單的說明,也可能是更複雜的,在這種情況下,可以使用CarePlan resource。


    If the procedure required specific follow up - e.g. removal of sutures. The follow up may be represented as a simple note or could potentially be more complex, in which case the CarePlan resource can be used.

    Short追蹤說明。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。[應填入於門診病歷數量Amount、頻率Frequency與單位Units]Instructions for follow up
    Comments

    Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

    Control30..*
    This element is affected by the following invariants: ele-1
    BindingUnless not suitable, these codes SHALL be taken from For example codes, see ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followup
    (extensible to http://hl7.org/fhir/ValueSet/procedure-followup)

    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。


    Specific follow up required for a procedure e.g. removal of sutures.

    TypeCodeableConcept(TW CodeableConcept)
    Is Modifierfalse
    Must Supporttrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    50. Procedure.note
    Definition

    關於此處置/手術的任何其他註釋和意見


    Any other notes and comments about the procedure.

    Short關於此處置/手術的附加資訊Additional information about the procedure
    Control0..*
    TypeAnnotation
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    52. Procedure.note.text
    Definition

    The text of the annotation in markdown format.

    ShortThe annotation - text content (as markdown)。[應填入於門診病歷註記或自費註記 Note/Self-pay note]
    Control1..1
    Typemarkdown
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

    Guidance on how to interpret the contents of this table can be found here

    0. Procedure
    Definition

    正在或曾經對病人執行的動作。這可以是像手術這樣的身體介入,也可以是像長照服務、諮詢或催眠療法這樣的非侵入性介入。HL7 FHIR官網另有提到的例子包括例如包括診斷處置/手術、內視鏡處置/手術、活體組織切片、諮詢、物理治療、個人支持服務、日照服務、非緊急運輸、改善家居設施、健身活動等。處置/手術可以由醫護人員、服務提供人員、朋友或親屬或在某些情況下由病人自己執行。

    Short正在或曾經對病人執行的動作
    Control0..*
    Is Modifierfalse
    Summaryfalse
    Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
    dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
    dom-6: A resource should have narrative for robust management (text.`div`.exists())
    2. Procedure.id
    Definition

    resource的邏輯ID,在resource的URL中使用。一旦指定,這個值永遠不會改變。

    Short不重複的ID用以識別儲存在特定FHIR Server中的Procedure紀錄,通常又稱為邏輯性ID。
    Comments

    一個resource使用新增操作(create operation)提交給伺服器時,此resource沒有id,它的id在resource被創建後由伺器分配/指定。

    Control0..1
    Typeid
    Is Modifierfalse
    Summarytrue
    4. Procedure.meta
    Definition

    關於resource的metadata。這是由基礎建設維護的內容。內容的更改可能並不總是與resource的版本更改相關聯。

    Short此Procedure Resource的metadata
    Control0..1
    TypeMeta
    Is Modifierfalse
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    6. Procedure.implicitRules
    Definition

    構建resource時遵循的一系列規則的參照,在處理內容時必須理解這些規則。通常這是對IG所定義之特殊規則及其他profiles的參照。

    Short創建此內容所依據的一組規則
    Comments

    宣告這套規則限制了內容只能被有限的交易夥伴所理解。這從本質上限制了資料的長期有用性。然而,現有的健康生態體系高度分裂,還沒有準備好以普遍可計算的方式定義、收集和交換資料。只要有可能,實作者和/或規範編寫者應該避免使用這個資料項目。通常在使用時,此URL是對IG的參照,此IG將這些特殊規則與其他profiles、value sets等一起定義為其敘述的一部分。

    Control0..1
    Typeuri
    Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    8. Procedure.language
    Definition

    編寫此resource的語言

    Short用以表述Procedure Resource內容的語言。
    Comments

    提供語言是為了支援索引和可存取性(通常,文字表述轉語音等服務使用此語言標籤)。html lanuage tag適用於此敘述。resource上的語言標籤可用於指定從resource中的資料所產成的其他表述之語言。不是所有的內容都必須使用此語言。不應該假定Resource.language自動適用於敘述。如果指定語言,它也應該被指定在html中的div資料項目(關於xml:lang和html lang屬性之間的關係,見HTML5中的規則)。

    Control0..1
    BindingThe codes SHOULD be taken from CommonLanguages
    (preferred to http://hl7.org/fhir/ValueSet/languages)

    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。

    Additional BindingsPurpose
    AllLanguagesMax Binding
    Typecode
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Example<br/><b>Value</b>:zh-TW
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    10. Procedure.text
    Definition

    人可讀的敘述,包含resource的摘要,可用於向人表述resource的內容。敘述不需要對所有的結構化資料進行編碼,但需要包含足夠的細節使人在閱讀敘述時理解「臨床安全性」。resource定義有哪些內容應該在敘述中表示,以確保臨床安全。

    ShortProcedure Resource之內容摘要以供人閱讀
    Comments

    內嵌(contained)的resource沒有敘述,非內嵌(contained)的resource則**建議應該(SHOULD)**有敘述。有時resource可能只有文字表述,很少或沒有額外的結構化資料(只要滿足所有minOccurs=1的資料項目)。這可能出現在舊系統的資料,當資訊以 「文字表述區塊(text blob) 」的形式被取得,或者文字表述是原始輸入或說明,而編碼資訊稍後再添加。

    Control0..1
    TypeNarrative
    Is Modifierfalse
    Summaryfalse
    Alternate Namesnarrative, html, xhtml, display
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    12. Procedure.contained
    Definition

    這些resource內嵌(contains)的resource不會另外存於任何FHIR伺服器,意即它們無法在任何FHIR伺服器中被找到,也無法有自己獨立的資料異動/交易(transaction)範圍。

    Short內嵌的(contained)、行內的Resources
    Comments

    當內容可以從任何FHIR伺服器找到時,不應該以內嵌(contained)resource的方式呈現,因為一旦失去識別,再次恢復它是非常困難的(並且取決於情境)。內嵌(contained)的resource可在它們的meta資料項目中表述profiles和tag,但不應該有安全標號(security labels)。

    Control0..*
    TypeResource
    Is Modifierfalse
    Summaryfalse
    Alternate Namesinline resources, anonymous resources, contained resources
    14. Procedure.extension
    Definition

    可用於表示不屬於此resource基本定義的額外資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,必須(SHALL) 滿足一系列要求。

    Short擴充的資料項目
    Comments

    任何應用程式、專案或標準使用擴充時,都不應該帶有任何負面的聯想。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    16. Procedure.modifierExtension
    Definition

    可以用來表示不屬於此resource的基本定義的額外資訊,並修改包含它所內嵌(contained)的資料項目的理解和/或對包含資料項目之後續使用的理解。通常修飾用的資料項目提供否定或限定的資訊。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。雖然任何實作者都可以定義一個擴充,但在定義擴充時 必須(SHALL) 滿足一組要求。處理resource的應用程式需要檢查修飾用的擴充資料項目。
    修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。

    Short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。
    Comments

    任何應用程式、專案或標準使用擴充時,都不應該帶有任何負面的聯想。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
    Summaryfalse
    Requirements

    修飾用的資料項目擴充允許將不能安全地忽略的擴充,與絕大多數可以安全地忽略的擴充明確區分開來。這樣做有助於促進可互操作性,因為無需禁止實作者使用擴充,想要瞭解更多資訊,請參見[修飾用的資料項目擴充之定義](http://hl7.org/fhir/R4/extensibility.html#modifierExtension)。

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    18. Procedure.identifier
    Definition

    由執行者或其他系統指定給此處置/手術的業務用識別碼,即使此resource作更新及在伺服器之間的傳遞,此識別碼仍保持不變。

    Short此處置/手術的外部識別碼。[應填入門診病歷項次Item]
    Comments

    這是一個業務識別碼,不是一個resource識別碼(詳見討論)。最好的做法是該識別碼只出現在單個resource實例上,但是業務實務有可能會規定可以在多個resource實例中具有相同識別碼—甚至可能具有不同的resource型例。例如:多個 「Patient(病人)」和 「Person(個人)」resource實例可能共用同一個社會保險號碼。

    NoteThis is a business identifier, not a resource identifier (see discussion)
    Control1..*
    TypeIdentifier
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Requirements

    允許識別各參與系統所知的此處置/手術資訊,並在各伺服器之間保持一致的方式。

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    20. Procedure.identifier.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    22. Procedure.identifier.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    SlicingThis element introduces a set of slices on Procedure.identifier.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • value @ url
    • 24. Procedure.identifier.use
      Definition

      The purpose of this identifier.

      Shortusual | official | temp | secondary | old (If known)
      Comments

      Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

      Control0..1
      BindingThe codes SHALL be taken from IdentifierUse
      (required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1)

      Identifies the purpose for this identifier, if known .

      Typecode
      Is Modifiertrue because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summarytrue
      Requirements

      Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      26. Procedure.identifier.type
      Definition

      A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

      ShortDescription of identifier
      Comments

      This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

      Control0..1
      BindingUnless not suitable, these codes SHALL be taken from Identifier Type Codes
      (extensible to http://hl7.org/fhir/ValueSet/identifier-type)

      A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

      TypeCodeableConcept
      Is Modifierfalse
      Summarytrue
      Requirements

      Allows users to make use of identifiers when the identifier system is not known.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      28. Procedure.identifier.system
      Definition

      Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

      ShortThe namespace for the identifier value
      Comments

      Identifier.system is always case sensitive.

      Control0..1
      Typeuri
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

      Example<br/><b>General</b>:http://www.acme.com/identifiers/patient
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      30. Procedure.identifier.value
      Definition

      The portion of the identifier typically relevant to the user and which is unique within the context of the system.

      ShortThe value that is unique
      Comments

      If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

      Control1..1
      Typestring
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Example<br/><b>General</b>:123456
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      32. Procedure.identifier.period
      Definition

      Time period during which identifier is/was valid for use.

      ShortTime period when id is/was valid for use
      Control0..1
      TypePeriod
      Is Modifierfalse
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      34. Procedure.identifier.assigner
      Definition

      Organization that issued/manages the identifier.

      ShortOrganization that issued id (may be just text)
      Comments

      The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

      Control0..1
      TypeReference(Organization)
      Is Modifierfalse
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      36. Procedure.instantiatesCanonical
      Definition

      指向此處置/手術全部或部分遵守的FHIR定義的計畫書(protocol)、指南(guideline)、醫令集(orderset)或其他定義的URL。

      Short實例化FHIR計畫書(protocol)或定義
      Control0..*
      Typecanonical(PlanDefinition, ActivityDefinition, Measure, OperationDefinition, Questionnaire)
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      38. Procedure.instantiatesUri
      Definition

      指向此處置/手術全部或部分的外部維護之計畫書(protocol)、指南(guideline)、醫令集(orderset)或其他定義的URL。

      Short實例化外部計畫書(protocol)或定義
      Comments

      這可能是一個HTML頁面、PDF等,也可能只是一個不可分解的URI識別碼。

      Control0..*
      Typeuri
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      40. Procedure.basedOn
      Definition

      對一個resource的參照,此resource包含此處置/手術請求的細節。

      Short此Procedure是基於什麼而履行?
      Control0..*
      TypeReference(CarePlan, ServiceRequest)
      Is Modifierfalse
      Summarytrue
      Alternate Namesfulfills
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      42. Procedure.partOf
      Definition

      這個特定的處置/手術是一個更大的事件中的一個組成部分或步驟

      Short參照事件的一部分
      Comments

      MedicationAdministration.partOf有一個Procedure參照,但這不是一個迴圈參照。例如:麻醉的給藥(MedicationAdministration)是手術處置/手術的一部分(MedicationAdministration.partOf = Procedure)。例如:為靜脈給藥插入靜脈口的處置/手術是給藥的一部分(Procedure.partOf = MedicationAdministration)。

      Control0..*
      TypeReference(TW Core Procedure, TW Core Observation Laboratory Result, MedicationAdministration)
      Is Modifierfalse
      Summarytrue
      Alternate Namescontainer
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      44. Procedure.status
      Definition

      一個指定處置/手術當前狀態的代碼。一般來說,它是進行中或完成的狀態。

      Shortpreparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknown
      Comments

      「未知」代碼不能用來表達其他狀態。當其中一個狀態適用時但編輯系統不知道此處置/手術的當前狀態,應該使用「未知」代碼。

      此資料項目被標記為修飾用,因為狀態包含標記resource當前無效的代碼。

      Control1..1
      BindingThe codes SHALL be taken from EventStatus
      (required to http://hl7.org/fhir/ValueSet/event-status|4.0.1)

      應填入所綁定值集中的其中一個代碼

      Typecode
      Is Modifiertrue because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Fixed Valuecompleted
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      46. Procedure.statusReason
      Definition

      捕捉Procedure當前狀態的原因

      Short當前狀態的原因。
      Comments

      這通常只用於「例外」狀態像是「未完成」、「暫停」或「終止」。執行此處置/手術的原因是在reasonCode中說明,而不是在這裡。

      Control0..1
      This element is affected by the following invariants: ele-1
      BindingUnless not suitable, these codes SHALL be taken from ProcedureNotPerformedReason(SNOMED-CT)
      (extensible to http://hl7.org/fhir/ValueSet/procedure-not-performed-reason)

      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。

      TypeCodeableConcept(TW CodeableConcept)
      Is Modifierfalse
      Alternate NamesSuspended Reason, Cancelled Reason
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      48. Procedure.category
      Definition

      對處置/手術進行分類的代碼(例如:「手術處置/手術」)。主要為了搜尋、排序和顯示時使用。

      Short處置/手術的分類。
      Comments

      Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

      Control0..1
      This element is affected by the following invariants: ele-1
      BindingUnless not suitable, these codes SHALL be taken from ProcedureCategoryCodes(SNOMEDCT)
      (extensible to http://hl7.org/fhir/ValueSet/procedure-category)

      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。

      TypeCodeableConcept(TW CodeableConcept)
      Is Modifierfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      50. Procedure.code
      Definition

      所進行的特定處置。如果不能對處置的確切種類進行編碼,則使用文字(例如:「腹腔鏡闌尾切除術」)。 處置代碼Procedure Code對應至Coding.code 處置名稱Procedure Name對應至Coding.display

      Short處置的識別碼。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。[應填入於門診病歷處置代碼Procedure Code與處置名稱Procedure Name]
      Comments

      Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

      Control1..1
      This element is affected by the following invariants: ele-1
      BindingFor example codes, see ProcedureCodes(SNOMEDCT)
      (example to http://hl7.org/fhir/ValueSet/procedure-code)

      A code to identify a specific procedure .

      TypeCodeableConcept(TW CodeableConcept)
      Is Modifierfalse
      Must Supporttrue
      Requirements

      0..1主要僅用於解釋敘述性的resource。

      Alternate Namestype
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      52. Procedure.code.id
      Definition

      resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。

      Short唯一可識別ID,以供資料項目間相互參照。
      Control0..1
      Typestring
      Is Modifierfalse
      XML FormatIn the XML format, this property is represented as an attribute.
      Summaryfalse
      54. Procedure.code.extension
      Definition

      擴充的資料項目

      Short擴充的資料項目
      Comments

      無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

      Control0..*
      TypeExtension
      Is Modifierfalse
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      SlicingThis element introduces a set of slices on Procedure.code.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • value @ url
      • 56. Procedure.code.coding
        Definition

        由專門術語系統(terminology system)所定義之代碼的參照。

        Short由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。
        Comments

        代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

        Control0..*
        This element is affected by the following invariants: ele-1
        TypeCoding(TW Coding)
        Is Modifierfalse
        Must Supporttrue
        Requirements

        允許使用者在不知道識別碼系統的情況下利用識別碼

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        SlicingThis element introduces a set of slices on Procedure.code.coding. The slices areUnordered and Open, and can be differentiated using the following discriminators:
        • pattern @ $this
        • 58. Procedure.code.coding:icd10-pcs-2021
          Slice Nameicd10-pcs-2021
          Definition

          由專門術語系統(terminology system)所定義之代碼的參照。

          Short此為臺灣衛生福利部中央健康保險署(NHI)維護之2021年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。
          Comments

          代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

          Control0..1
          This element is affected by the following invariants: ele-1
          BindingThe codes SHALL be taken from 臺灣健保署2021年中文版ICD-10-PCS值集
          (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw)

          處置/手術的識別;應填入所綁定值集中的其中一個代碼。

          TypeCoding(TW Coding)
          Is Modifierfalse
          Must Supporttrue
          Requirements

          允許使用者在不知道識別碼系統的情況下利用識別碼

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          60. Procedure.code.coding:icd10-pcs-2014
          Slice Nameicd10-pcs-2014
          Definition

          由專門術語系統(terminology system)所定義之代碼的參照。

          Short此為臺灣衛生福利部中央健康保險署(NHI)維護之2014年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。
          Comments

          代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

          Control0..1
          This element is affected by the following invariants: ele-1
          BindingThe codes SHALL be taken from 臺灣健保署2014年中文版ICD-10-PCS值集
          (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2014-tw)

          處置/手術的識別;應填入所綁定值集中的其中一個代碼。

          TypeCoding(TW Coding)
          Is Modifierfalse
          Must Supporttrue
          Requirements

          允許使用者在不知道識別碼系統的情況下利用識別碼

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          62. Procedure.code.coding:icd9-cm-2001
          Slice Nameicd9-cm-2001
          Definition

          由專門術語系統(terminology system)所定義之代碼的參照

          Short由專門術語系統(terminology system)定義的代碼
          Comments

          代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,例如:SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

          Control0..1
          This element is affected by the following invariants: ele-1
          BindingThe codes SHALL be taken from 臺灣健保署2001年中文版ICD-9-CM值集
          (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw)
          TypeCoding(TW Coding)
          Is Modifierfalse
          Must Supporttrue
          Requirements

          允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          64. Procedure.code.coding:medical-service-payment
          Slice Namemedical-service-payment
          Definition

          由專門術語系統(terminology system)所定義之代碼的參照。

          Short此為臺灣衛生福利部中央健康保險署(NHI)維護之醫療服務給付項目,主要針對申報使用,可免費使用,可依情境選用此代碼。
          Comments

          代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

          Control0..1
          This element is affected by the following invariants: ele-1
          BindingThe codes SHALL be taken from 臺灣衛福部統計處藥品使用頻率值集
          (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/medication-frequency-tw)

          處置/手術的識別;應填入所綁定值集中的其中一個代碼。

          TypeCoding(TW Coding)
          Is Modifierfalse
          Must Supporttrue
          Requirements

          允許使用者在不知道識別碼系統的情況下利用識別碼

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          66. Procedure.code.coding:sct-procedures
          Slice Namesct-procedures
          Definition

          由專門術語系統(terminology system)所定義之代碼的參照。

          Short此為SNOMED CT處置/手術代碼,若機構已有購買相關授權,亦可使用。
          Comments

          代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

          Control0..1
          This element is affected by the following invariants: ele-1
          BindingThe codes SHALL be taken from ProcedureCodes(SNOMEDCT)
          (required to http://hl7.org/fhir/ValueSet/procedure-code)

          處置/手術的識別;應填入所綁定值集中的其中一個代碼。

          TypeCoding(TW Coding)
          Is Modifierfalse
          Must Supporttrue
          Requirements

          允許使用者在不知道識別碼系統的情況下利用識別碼

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          68. Procedure.code.text
          Definition

          輸入資料的使用者所見/所選/所說的人類可讀文字表述,和(或)其代表使用者的預期含義。

          Short概念的文字表示法
          Comments

          很多時候,此文字表述與其中一個代碼的顯示名稱相同。

          Control0..1
          Typestring
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Must Supporttrue
          Summarytrue
          Requirements

          專門術語中的代碼並不總是能捕捉人類使用的細微差別的正確意義,或者根本就沒有合適的代碼;這些情況下,文字表述被用來捕捉來源的全部意義。

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          70. Procedure.subject
          Definition

          進行處置/手術的病人、動物或實體集合(例如:特定的一群人)。

          Short誰有此病情、問題或診斷?
          Control1..1
          TypeReference(門診病歷-病人基本資料)
          Is Modifierfalse
          Must Supporttrue
          Summarytrue
          Alternate Namespatient
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          72. Procedure.encounter
          Definition

          此「處置/手術(Procedure)」記載在哪次的「就醫(Encounter)」紀錄或者與此處置/手術紀錄密切相關的「就醫(Encounter)」紀錄

          Short就醫(Encounter)紀錄作為處置/手術的一部分
          Comments

          通常是此處置/手術發生的就醫事件(Encounter),雖然有些活動可能在就醫結束之前或之後開始,但仍與就醫事件的情境有關。這筆紀錄表明與此處置/手術紀錄相關的就醫事件。

          Control0..1
          TypeReference(TW Core Encounter)
          Is Modifierfalse
          Summarytrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          74. Procedure.performed[x]
          Definition

          進行處置/手術的估計或實際日期、日期時間、時間區間或年齡。允許一個時間區間來支持跨越一個日期以上的複雜處置/手術,也允許捕捉處置/手術的執行時間長度。

          Short此處置/手術何時執行的?
          Comments

          年齡一般用於病人報告其進行手術的年齡,像是20到25歲時。 dateTime支援一定的精度範圍,因為有些處置/手術被報告為過去的處置/手術,可能沒有毫秒的精度,而其他在就醫期間執行和記錄的處置/手術可能有更精確的UTC時間戳記和時區。

          Control0..1
          TypeChoice of: dateTime, Period, string, Age, Range
          [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Must Supporttrue
          Must Support TypesdateTime
          Summarytrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          76. Procedure.recorder
          Definition

          記錄處置/手術內容並對其內容負責的個人

          Short誰記錄此處置/手術
          Control0..1
          TypeReference(TW Core Patient, TW Core Practitioner, TW Core PractitionerRole, RelatedPerson)
          Is Modifierfalse
          Summarytrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          78. Procedure.asserter
          Definition

          提出此處置/手術說明的人

          Short聲稱有此處置/手術的人
          Control0..1
          TypeReference(TW Core Patient, RelatedPerson, TW Core Practitioner, TW Core PractitionerRole)
          Is Modifierfalse
          Must Supporttrue
          Must Support TypesNo must-support rules about the choice of types/profiles
          Summarytrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          80. Procedure.performer
          Definition

          限於「真正的」人而不是設備

          Short執行處置/手術的人員
          Control0..*
          TypeBackboneElement
          Is Modifierfalse
          Must Supporttrue
          Summarytrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          82. Procedure.performer.id
          Definition

          resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。

          Short唯一可識別ID,以供資料項目間相互參照。
          Control0..1
          Typestring
          Is Modifierfalse
          XML FormatIn the XML format, this property is represented as an attribute.
          Summaryfalse
          84. Procedure.performer.extension
          Definition

          可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

          Short擴充的資料項目
          Comments

          無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

          Control0..*
          TypeExtension
          Is Modifierfalse
          Summaryfalse
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          86. Procedure.performer.modifierExtension
          Definition

          可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。 修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。

          Short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。
          Comments

          無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

          Control0..*
          TypeExtension
          Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
          Summarytrue
          Requirements

          修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互通性。更多訊息,請參見修飾用的資料項目擴充之定義

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          88. Procedure.performer.function
          Definition

          區分執行者在處置/手術中的參與型別,例如:外科醫生、麻醉師、內視鏡醫生。

          Short執行的型別
          Comments

          Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

          Control0..1
          This element is affected by the following invariants: ele-1
          BindingUnless not suitable, these codes SHALL be taken from ProcedurePerformerRoleCodes
          (extensible to http://hl7.org/fhir/ValueSet/performer-role)

          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。

          TypeCodeableConcept(TW CodeableConcept)
          Is Modifierfalse
          Requirements

          允許針對不同執行者的參與型別進行澄清以消除歧義

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          90. Procedure.performer.actor
          Definition

          參與處置/手術的健康照護服務提供者

          Short參照至健康照護服務提供者
          Control1..1
          TypeReference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, TW Core Patient, RelatedPerson, Device)
          Is Modifierfalse
          Must Supporttrue
          Must Support TypesNo must-support rules about the choice of types/profiles
          Summarytrue
          Requirements

          一個參照至裝置(Device)的使用案例,例如:心律調整器。

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          92. Procedure.performer.onBehalfOf
          Definition

          此裝置或健康照護服務提供者所代表的機構

          Short此裝置(Device)或健康照護服務提供者所屬機構(Organization)
          Control0..1
          TypeReference(TW Core Organization)
          Is Modifierfalse
          Must Supporttrue
          Summaryfalse
          Requirements

          健康照護服務提供者和裝置可以與多個機構相關聯,此資料項目表明他們在執行行動時代表哪個機構。

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          94. Procedure.location
          Definition

          實際發生處置/手術的地點(Location)。例如:新生兒在家裡出生、在餐廳做氣管切開術。

          Short處置/手術發生的地點(Location)?
          Control0..1
          TypeReference(TW Core Location)
          Is Modifierfalse
          Summarytrue
          Requirements

          將一個處置/手術與可能保存紀錄的地點(Location)聯繫起來

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          96. Procedure.reasonCode
          Definition

          進行此處置/手術的原因代碼。這可能是某種型別的編碼,也可能只是文字表述。

          Short處置/手術執行原因代碼
          Comments

          當一個代碼足以描述原因時,使用Procedure.reasonCode。當參照一個resource時,使用Procedure.reasonReference以傳達更多的資訊,如發病日期。Procedure.reasonCode和Procedure.reasonReference不應該是重複的。對於一個單一的原因,Procedure.reasonCode或Procedure.reasonReference都可以被使用。Procedure.reasonCode可以是一個摘要代碼,或者Procedure.reasonReference可以用Condition | Observation | Procedure | DiagnosticReport | DocumentReference來參照一個非常精確的原因定義。如果Procedure.reasonCode和Procedure.reasonReference描述的是處置/手術的不同原因,則兩者都可以使用。

          Control0..*
          This element is affected by the following invariants: ele-1
          BindingUnless not suitable, these codes SHALL be taken from ProcedureReasonCodes
          (extensible to http://hl7.org/fhir/ValueSet/procedure-reason)

          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。

          TypeCodeableConcept(TW CodeableConcept)
          Is Modifierfalse
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          98. Procedure.reasonReference
          Definition

          為什麼進行此處置/手術的原因

          Short執行此處置/手術的原因
          Comments

          一個處置/手術有可能成為另一個處置/手術(如C-Section)的理由(如硬膜外)。其他的例子包括擴張的內窺鏡檢查和活檢(診斷和治療的結合)。 當一個代碼充分地描述了原因時,使用Procedure.reasonCode。當引用一個resource時,使用Procedure.reasonReference,這樣可以傳達更多的資訊,如發病日期。Procedure.reasonCode和Procedure.reasonReference不應該是重複的。對於一個單一的原因,Procedure.reasonCode或Procedure.reasonReference都可以被使用。Procedure.reasonCode可以是一個摘要代碼,或者Procedure.reasonReference可以用Condition | Observation | Procedure | DiagnosticReport | DocumentReference來引用一個非常精確的原因定義。如果Procedure.reasonCode和Procedure.reasonReference描述的是處置/手術的不同原因,則兩者都可以使用。

          Control0..*
          TypeReference(TW Core Condition, TW Core Observation Laboratory Result, TW Core Procedure, DiagnosticReport, DocumentReference)
          Is Modifierfalse
          Summarytrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          100. Procedure.bodySite
          Definition

          詳細和結構化的解剖學位置資訊。允許多個位置—例如:一個病灶的多個活體組織切片。

          Short目標身體部位。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。[應填入於門診病歷部位Part]
          Comments

          如果案例需要BodySite resource的屬性(例如:識別和各別追蹤),那麼就使用標準擴充[procedure-targetbodystructure](擴充-procedure-targetbodystructure.html)。

          Control0..*
          This element is affected by the following invariants: ele-1
          BindingUnless not suitable, these codes SHALL be taken from SNOMEDCTBodyStructures
          (extensible to http://hl7.org/fhir/ValueSet/body-site)

          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。

          TypeCodeableConcept(TW CodeableConcept)
          Is Modifierfalse
          Must Supporttrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          102. Procedure.outcome
          Definition

          處置/手術的結果—它是否解決了當初執行處置/手術所要解決的問題?

          Short處置/手術的結果。
          Comments

          如果結果只包含敘述性文字,可用CodeableConcept.text來說明。

          Control0..1
          This element is affected by the following invariants: ele-1
          BindingUnless not suitable, these codes SHALL be taken from ProcedureOutcomeCodes(SNOMEDCT)
          (extensible to http://hl7.org/fhir/ValueSet/procedure-outcome)

          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。

          TypeCodeableConcept(TW CodeableConcept)
          Is Modifierfalse
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          104. Procedure.report
          Definition

          這可能是組織學結果、病理學報告、手術報告等。

          Short此處置/手術產生的任何報告
          Comments

          有可能會有多份報告—例如:如果這是一個需要進行多次活體組織切片的處置/手術,會產生一些解剖病理報告。

          Control0..*
          TypeReference(DiagnosticReport, DocumentReference, Composition)
          Is Modifierfalse
          Summaryfalse
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          106. Procedure.complication
          Definition

          在處置/手術過程中,或在處置/手術後不久發生的任何併發症。這些通常與紀錄分開追蹤,紀錄通常描述處置/手術本身,而不是任何 「處置/手術後」的問題。

          Short處置/手術後的併發症
          Comments

          如果併發症僅由敘述性文字表達,可用CodeableConcept.text來說明。

          Control0..*
          This element is affected by the following invariants: ele-1
          BindingUnless not suitable, these codes SHALL be taken from Condition/Problem/DiagnosisCodes
          (extensible to http://hl7.org/fhir/ValueSet/condition-code)

          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。

          TypeCodeableConcept(TW CodeableConcept)
          Is Modifierfalse
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          108. Procedure.complicationDetail
          Definition

          在處置/手術過程中或在執行結束後立即發生的任何併發症

          Short處置/手術後發生的病情、問題或診斷
          Control0..*
          TypeReference(TW Core Condition)
          Is Modifierfalse
          Summaryfalse
          Requirements

          這是用來記錄作為處置/手術結果的病情、問題或診斷,而不是作為處置/手術原因的病情、問題或診斷。

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          110. Procedure.followUp
          Definition

          如果該處置/手術需要特定的後續行動—例如拆除縫線。 後續行動可以表現為一個簡單的說明,也可能是更複雜的,在這種情況下,可以使用CarePlan resource。

          Short追蹤說明。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。[應填入於門診病歷數量Amount、頻率Frequency與單位Units]
          Comments

          Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

          Control3..*
          This element is affected by the following invariants: ele-1
          BindingUnless not suitable, these codes SHALL be taken from ProcedureFollowUpCodes(SNOMEDCT)
          (extensible to http://hl7.org/fhir/ValueSet/procedure-followup)

          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。

          TypeCodeableConcept(TW CodeableConcept)
          Is Modifierfalse
          Must Supporttrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          112. Procedure.note
          Definition

          關於此處置/手術的任何其他註釋和意見

          Short關於此處置/手術的附加資訊
          Control0..*
          TypeAnnotation
          Is Modifierfalse
          Must Supporttrue
          Summaryfalse
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          114. Procedure.note.id
          Definition

          Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

          ShortUnique id for inter-element referencing
          Control0..1
          Typestring
          Is Modifierfalse
          XML FormatIn the XML format, this property is represented as an attribute.
          Summaryfalse
          116. Procedure.note.extension
          Definition

          May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

          ShortAdditional content defined by implementations
          Comments

          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

          Control0..*
          TypeExtension
          Is Modifierfalse
          Summaryfalse
          Alternate Namesextensions, user content
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          SlicingThis element introduces a set of slices on Procedure.note.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
          • value @ url
          • 118. Procedure.note.author[x]
            Definition

            The individual responsible for making the annotation.

            ShortIndividual responsible for the annotation
            Comments

            Organization is used when there's no need for specific attribution as to who made the comment.

            Control0..1
            TypeChoice of: Reference(Practitioner, Patient, RelatedPerson, Organization), string
            [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            120. Procedure.note.time
            Definition

            Indicates when this particular annotation was made.

            ShortWhen the annotation was made
            Control0..1
            TypedateTime
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            122. Procedure.note.text
            Definition

            The text of the annotation in markdown format.

            ShortThe annotation - text content (as markdown)。[應填入於門診病歷註記或自費註記 Note/Self-pay note]
            Control1..1
            Typemarkdown
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Must Supporttrue
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            124. Procedure.focalDevice
            Definition

            植入、移除或以其他方式操作的裝置(校準、更換電池、安裝義肢、安裝傷口真空裝置等),是處置/手術的重點部分。

            Short處理、植入的或移除的裝置
            Control0..*
            TypeBackboneElement
            Is Modifierfalse
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            126. Procedure.focalDevice.id
            Definition

            resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。

            Short唯一可識別ID,以供資料項目間相互參照。
            Control0..1
            Typestring
            Is Modifierfalse
            XML FormatIn the XML format, this property is represented as an attribute.
            Summaryfalse
            128. Procedure.focalDevice.extension
            Definition

            可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

            Short擴充的資料項目
            Comments

            無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

            Control0..*
            TypeExtension
            Is Modifierfalse
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            130. Procedure.focalDevice.modifierExtension
            Definition

            可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。 修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。

            Short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。
            Comments

            無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

            Control0..*
            TypeExtension
            Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
            Summarytrue
            Requirements

            修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互通性。更多訊息,請參見修飾用的資料項目擴充之定義

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            132. Procedure.focalDevice.action
            Definition

            處置/手術過程中,設備改變的類型。

            Short改變裝置的種類
            Comments

            Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

            Control0..1
            This element is affected by the following invariants: ele-1
            BindingThe codes SHOULD be taken from ProcedureDeviceActionCodes
            (preferred to http://hl7.org/fhir/ValueSet/device-action)

            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。

            TypeCodeableConcept(TW CodeableConcept)
            Is Modifierfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            134. Procedure.focalDevice.manipulated
            Definition

            在處置/手術中被處理(改變)的裝置

            Short被改變的裝置
            Control1..1
            TypeReference(Device)
            Is Modifierfalse
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            136. Procedure.usedReference
            Definition

            指明藥品、裝置和作為處置/手術一部分的任何其他物質

            Short處置/手術中使用的項目/物品
            Comments

            對於實際植入或取出的裝置,使用Procedure.device。

            Control0..*
            TypeReference(Device, Medication, Substance)
            Is Modifierfalse
            Summaryfalse
            Requirements

            用於追蹤污染等

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            138. Procedure.usedCode
            Definition

            指明作為處置/手術的一部分而使用的編碼項目

            Short處置/手術中使用的項目之代碼
            Comments

            對於實際植入或取出的裝置,使用Procedure.device。

            Control0..*
            This element is affected by the following invariants: ele-1
            BindingUnless not suitable, these codes SHALL be taken from FHIRDeviceTypes
            (extensible to http://hl7.org/fhir/ValueSet/device-kind)

            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。

            TypeCodeableConcept(TW CodeableConcept)
            Is Modifierfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))