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/PMRProcedure | Version: 0.1.0 | |||
Draft as of 2024-08-23 | Computable Name: PMRProcedure |
此Profile繼承於臺灣核心-處置(TW Core Procedure) ,並用於描述門診病歷中的處置項目[FMM1]
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from TWCoreProcedure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | 0..* | TWCoreProcedure | 正在或曾經對病人執行的動作 | |
identifier | S | 1..* | Identifier | 此處置/手術的外部識別碼。[應填入門診病歷項次Item] |
system | S | 0..1 | uri | The namespace for the identifier value |
value | S | 1..1 | string | The value that is unique |
status | 1..1 | code | preparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknown Fixed Value: completed | |
code | 1..1 | CodeableConceptTW | 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] | |
subject | 1..1 | Reference(門診病歷-病人基本資料) | 誰有此病情、問題或診斷? | |
bodySite | 0..* | CodeableConceptTW | 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] | |
followUp | S | 3..* | CodeableConceptTW | 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] |
note | S | 0..* | Annotation | 關於此處置/手術的附加資訊 |
text | S | 1..1 | markdown | The annotation - text content (as markdown)。[應填入於門診病歷註記或自費註記 Note/Self-pay note] |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | 0..* | TWCoreProcedure | 正在或曾經對病人執行的動作 | |
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 |
modifierExtension | ?! | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 |
identifier | SΣ | 1..* | Identifier | 此處置/手術的外部識別碼。[應填入門診病歷項次Item] |
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
system | SΣ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
value | SΣ | 1..1 | string | The value that is unique Example General: 123456 |
status | ?!SΣ | 1..1 | code | preparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknown Binding: EventStatus (required): 應填入所綁定值集中的其中一個代碼 Fixed Value: completed |
code | S | 1..1 | CodeableConceptTW | 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] Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . |
Slices for coding | S | 0..* | CodingTW | 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。 Slice: Unordered, Open by pattern:$this |
coding:icd10-pcs-2021 | S | 0..1 | CodingTW | 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。 Binding: 臺灣健保署2021年中文版ICD-10-PCS值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 |
coding:icd10-pcs-2014 | S | 0..1 | CodingTW | 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。 Binding: 臺灣健保署2014年中文版ICD-10-PCS值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 |
coding:icd9-cm-2001 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required) |
coding:medical-service-payment | S | 0..1 | CodingTW | 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。 Binding: 臺灣衛福部統計處藥品使用頻率值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 |
coding:sct-procedures | S | 0..1 | CodingTW | 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。 Binding: ProcedureCodes(SNOMEDCT) (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 |
text | SΣ | 0..1 | string | 概念的文字表示法 |
subject | SΣ | 1..1 | Reference(門診病歷-病人基本資料) | 誰有此病情、問題或診斷? |
performed[x] | SΣ | 0..1 | 此處置/手術何時執行的? | |
performedDateTime | dateTime | |||
asserter | SΣ | 0..1 | Reference(TW Core Patient | RelatedPerson | TW Core Practitioner | TW Core PractitionerRole) | 聲稱有此處置/手術的人 |
performer | SΣ | 0..* | BackboneElement | 執行處置/手術的人員 |
modifierExtension | ?!Σ | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 |
actor | SΣ | 1..1 | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | TW Core Patient | RelatedPerson | Device) | 參照至健康照護服務提供者 |
onBehalfOf | S | 0..1 | Reference(TW Core Organization) | 此裝置(Device)或健康照護服務提供者所屬機構(Organization) |
bodySite | S | 0..* | CodeableConceptTW | 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] Binding: SNOMEDCTBodyStructures (extensible): 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。 |
followUp | S | 3..* | CodeableConceptTW | 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] Binding: ProcedureFollowUpCodes(SNOMEDCT) (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 |
note | S | 0..* | Annotation | 關於此處置/手術的附加資訊 |
text | SΣ | 1..1 | markdown | The annotation - text content (as markdown)。[應填入於門診病歷註記或自費註記 Note/Self-pay note] |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Procedure.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | |
Procedure.status | required | Fixed Value: completedhttp://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard | |
Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | |
Procedure.code.coding:icd10-pcs-2021 | required | TW2021ICD10PCShttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw | |
Procedure.code.coding:icd10-pcs-2014 | required | TW2014ICD10PCShttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2014-tw | |
Procedure.code.coding:icd9-cm-2001 | required | TW2001ICD9CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw | |
Procedure.code.coding:medical-service-payment | required | TWMedicationFrequencyhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/medication-frequency-tw | |
Procedure.code.coding:sct-procedures | required | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | |
Procedure.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | |
Procedure.followUp | extensible | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Procedure | 0..* | TWCoreProcedure | 正在或曾經對病人執行的動作 | |||||
id | Σ | 0..1 | id | 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。 | ||||
meta | Σ | 0..1 | Meta | 此Procedure Resource的metadata | ||||
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 | ||||
language | 0..1 | code | 用以表述Procedure Resource內容的語言。 Binding: CommonLanguages (preferred): 人類語言;鼓勵使用CommonLanguages代碼表中的代碼,但不強制一定要使用此代碼表,你也可使用其他代碼表的代碼或單純以文字表示。
Example Value: zh-TW | |||||
text | 0..1 | Narrative | Procedure Resource之內容摘要以供人閱讀 | |||||
contained | 0..* | Resource | 內嵌的(contained)、行內的Resources | |||||
extension | 0..* | Extension | 擴充的資料項目 | |||||
modifierExtension | ?! | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 | ||||
identifier | SΣ | 1..* | Identifier | 此處置/手術的外部識別碼。[應填入門診病歷項次Item] | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
system | SΣ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | SΣ | 1..1 | string | The value that is unique Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | 實例化FHIR計畫書(protocol)或定義 | ||||
instantiatesUri | Σ | 0..* | uri | 實例化外部計畫書(protocol)或定義 | ||||
basedOn | Σ | 0..* | Reference(CarePlan | ServiceRequest) | 此Procedure是基於什麼而履行? | ||||
partOf | Σ | 0..* | Reference(TW Core Procedure | TW Core Observation Laboratory Result | MedicationAdministration) | 參照事件的一部分 | ||||
status | ?!SΣ | 1..1 | code | preparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknown Binding: EventStatus (required): 應填入所綁定值集中的其中一個代碼 Fixed Value: completed | ||||
statusReason | 0..1 | CodeableConceptTW | 當前狀態的原因。 Binding: ProcedureNotPerformedReason(SNOMED-CT) (extensible): 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。 | |||||
category | 0..1 | CodeableConceptTW | 處置/手術的分類。 Binding: ProcedureCategoryCodes(SNOMEDCT) (extensible): 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。 | |||||
code | S | 1..1 | CodeableConceptTW | 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] Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . | ||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 Slice: Unordered, Open by value:url | |||||
Slices for coding | S | 0..* | CodingTW | 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。 Slice: Unordered, Open by pattern:$this | ||||
coding:icd10-pcs-2021 | S | 0..1 | CodingTW | 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。 Binding: 臺灣健保署2021年中文版ICD-10-PCS值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:icd10-pcs-2014 | S | 0..1 | CodingTW | 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。 Binding: 臺灣健保署2014年中文版ICD-10-PCS值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:icd9-cm-2001 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required) | ||||
coding:medical-service-payment | S | 0..1 | CodingTW | 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。 Binding: 臺灣衛福部統計處藥品使用頻率值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:sct-procedures | S | 0..1 | CodingTW | 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。 Binding: ProcedureCodes(SNOMEDCT) (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
text | SΣ | 0..1 | string | 概念的文字表示法 | ||||
subject | SΣ | 1..1 | Reference(門診病歷-病人基本資料) | 誰有此病情、問題或診斷? | ||||
encounter | Σ | 0..1 | Reference(TW Core Encounter) | 就醫(Encounter)紀錄作為處置/手術的一部分 | ||||
performed[x] | SΣ | 0..1 | 此處置/手術何時執行的? | |||||
performedDateTime | dateTime S | |||||||
performedPeriod | Period | |||||||
performedString | string | |||||||
performedAge | Age | |||||||
performedRange | Range | |||||||
recorder | Σ | 0..1 | Reference(TW Core Patient | TW Core Practitioner | TW Core PractitionerRole | RelatedPerson) | 誰記錄此處置/手術 | ||||
asserter | SΣ | 0..1 | Reference(TW Core Patient | RelatedPerson | TW Core Practitioner | TW Core PractitionerRole) | 聲稱有此處置/手術的人 | ||||
performer | SΣ | 0..* | BackboneElement | 執行處置/手術的人員 | ||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 | |||||
modifierExtension | ?!Σ | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 | ||||
function | 0..1 | CodeableConceptTW | 執行的型別 Binding: ProcedurePerformerRoleCodes (extensible): 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。 | |||||
actor | SΣ | 1..1 | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | TW Core Patient | RelatedPerson | Device) | 參照至健康照護服務提供者 | ||||
onBehalfOf | S | 0..1 | Reference(TW Core Organization) | 此裝置(Device)或健康照護服務提供者所屬機構(Organization) | ||||
location | Σ | 0..1 | Reference(TW Core Location) | 處置/手術發生的地點(Location)? | ||||
reasonCode | 0..* | CodeableConceptTW | 處置/手術執行原因代碼 Binding: ProcedureReasonCodes (extensible): 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。 | |||||
reasonReference | Σ | 0..* | Reference(TW Core Condition | TW Core Observation Laboratory Result | TW Core Procedure | DiagnosticReport | DocumentReference) | 執行此處置/手術的原因 | ||||
bodySite | S | 0..* | CodeableConceptTW | 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] Binding: SNOMEDCTBodyStructures (extensible): 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。 | ||||
outcome | 0..1 | CodeableConceptTW | 處置/手術的結果。 Binding: ProcedureOutcomeCodes(SNOMEDCT) (extensible): 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。 | |||||
report | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | 此處置/手術產生的任何報告 | |||||
complication | 0..* | CodeableConceptTW | 處置/手術後的併發症 Binding: Condition/Problem/DiagnosisCodes (extensible): 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。 | |||||
complicationDetail | 0..* | Reference(TW Core Condition) | 處置/手術後發生的病情、問題或診斷 | |||||
followUp | S | 3..* | CodeableConceptTW | 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] Binding: ProcedureFollowUpCodes(SNOMEDCT) (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
note | S | 0..* | Annotation | 關於此處置/手術的附加資訊 | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
author[x] | Σ | 0..1 | Individual responsible for the annotation | |||||
authorReference | Reference(Practitioner | Patient | RelatedPerson | Organization) | |||||||
authorString | string | |||||||
time | Σ | 0..1 | dateTime | When the annotation was made | ||||
text | SΣ | 1..1 | markdown | The annotation - text content (as markdown)。[應填入於門診病歷註記或自費註記 Note/Self-pay note] | ||||
focalDevice | 0..* | BackboneElement | 處理、植入的或移除的裝置 | |||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 | |||||
modifierExtension | ?!Σ | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 | ||||
action | 0..1 | CodeableConceptTW | 改變裝置的種類 Binding: ProcedureDeviceActionCodes (preferred): 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。 | |||||
manipulated | 1..1 | Reference(Device) | 被改變的裝置 | |||||
usedReference | 0..* | Reference(Device | Medication | Substance) | 處置/手術中使用的項目/物品 | |||||
usedCode | 0..* | CodeableConceptTW | 處置/手術中使用的項目之代碼 Binding: FHIRDeviceTypes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Procedure.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
Procedure.identifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | ||||
Procedure.status | required | Fixed Value: completedhttp://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard | ||||
Procedure.statusReason | extensible | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard | ||||
Procedure.category | extensible | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard | ||||
Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | ||||
Procedure.code.coding:icd10-pcs-2021 | required | TW2021ICD10PCShttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw | ||||
Procedure.code.coding:icd10-pcs-2014 | required | TW2014ICD10PCShttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2014-tw | ||||
Procedure.code.coding:icd9-cm-2001 | required | TW2001ICD9CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw | ||||
Procedure.code.coding:medical-service-payment | required | TWMedicationFrequencyhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/medication-frequency-tw | ||||
Procedure.code.coding:sct-procedures | required | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | ||||
Procedure.performer.function | extensible | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard | ||||
Procedure.reasonCode | extensible | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard | ||||
Procedure.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Procedure.outcome | extensible | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard | ||||
Procedure.complication | extensible | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Procedure.followUp | extensible | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard | ||||
Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-action from the FHIR Standard | ||||
Procedure.usedCode | extensible | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from TWCoreProcedure
Differential View
This structure is derived from TWCoreProcedure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | 0..* | TWCoreProcedure | 正在或曾經對病人執行的動作 | |
identifier | S | 1..* | Identifier | 此處置/手術的外部識別碼。[應填入門診病歷項次Item] |
system | S | 0..1 | uri | The namespace for the identifier value |
value | S | 1..1 | string | The value that is unique |
status | 1..1 | code | preparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknown Fixed Value: completed | |
code | 1..1 | CodeableConceptTW | 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] | |
subject | 1..1 | Reference(門診病歷-病人基本資料) | 誰有此病情、問題或診斷? | |
bodySite | 0..* | CodeableConceptTW | 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] | |
followUp | S | 3..* | CodeableConceptTW | 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] |
note | S | 0..* | Annotation | 關於此處置/手術的附加資訊 |
text | S | 1..1 | markdown | The annotation - text content (as markdown)。[應填入於門診病歷註記或自費註記 Note/Self-pay note] |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | 0..* | TWCoreProcedure | 正在或曾經對病人執行的動作 | |
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 |
modifierExtension | ?! | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 |
identifier | SΣ | 1..* | Identifier | 此處置/手術的外部識別碼。[應填入門診病歷項次Item] |
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
system | SΣ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
value | SΣ | 1..1 | string | The value that is unique Example General: 123456 |
status | ?!SΣ | 1..1 | code | preparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknown Binding: EventStatus (required): 應填入所綁定值集中的其中一個代碼 Fixed Value: completed |
code | S | 1..1 | CodeableConceptTW | 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] Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . |
Slices for coding | S | 0..* | CodingTW | 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。 Slice: Unordered, Open by pattern:$this |
coding:icd10-pcs-2021 | S | 0..1 | CodingTW | 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。 Binding: 臺灣健保署2021年中文版ICD-10-PCS值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 |
coding:icd10-pcs-2014 | S | 0..1 | CodingTW | 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。 Binding: 臺灣健保署2014年中文版ICD-10-PCS值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 |
coding:icd9-cm-2001 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required) |
coding:medical-service-payment | S | 0..1 | CodingTW | 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。 Binding: 臺灣衛福部統計處藥品使用頻率值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 |
coding:sct-procedures | S | 0..1 | CodingTW | 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。 Binding: ProcedureCodes(SNOMEDCT) (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 |
text | SΣ | 0..1 | string | 概念的文字表示法 |
subject | SΣ | 1..1 | Reference(門診病歷-病人基本資料) | 誰有此病情、問題或診斷? |
performed[x] | SΣ | 0..1 | 此處置/手術何時執行的? | |
performedDateTime | dateTime | |||
asserter | SΣ | 0..1 | Reference(TW Core Patient | RelatedPerson | TW Core Practitioner | TW Core PractitionerRole) | 聲稱有此處置/手術的人 |
performer | SΣ | 0..* | BackboneElement | 執行處置/手術的人員 |
modifierExtension | ?!Σ | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 |
actor | SΣ | 1..1 | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | TW Core Patient | RelatedPerson | Device) | 參照至健康照護服務提供者 |
onBehalfOf | S | 0..1 | Reference(TW Core Organization) | 此裝置(Device)或健康照護服務提供者所屬機構(Organization) |
bodySite | S | 0..* | CodeableConceptTW | 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] Binding: SNOMEDCTBodyStructures (extensible): 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。 |
followUp | S | 3..* | CodeableConceptTW | 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] Binding: ProcedureFollowUpCodes(SNOMEDCT) (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 |
note | S | 0..* | Annotation | 關於此處置/手術的附加資訊 |
text | SΣ | 1..1 | markdown | The annotation - text content (as markdown)。[應填入於門診病歷註記或自費註記 Note/Self-pay note] |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Procedure.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | |
Procedure.status | required | Fixed Value: completedhttp://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard | |
Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | |
Procedure.code.coding:icd10-pcs-2021 | required | TW2021ICD10PCShttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw | |
Procedure.code.coding:icd10-pcs-2014 | required | TW2014ICD10PCShttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2014-tw | |
Procedure.code.coding:icd9-cm-2001 | required | TW2001ICD9CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw | |
Procedure.code.coding:medical-service-payment | required | TWMedicationFrequencyhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/medication-frequency-tw | |
Procedure.code.coding:sct-procedures | required | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | |
Procedure.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | |
Procedure.followUp | extensible | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Procedure | 0..* | TWCoreProcedure | 正在或曾經對病人執行的動作 | |||||
id | Σ | 0..1 | id | 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。 | ||||
meta | Σ | 0..1 | Meta | 此Procedure Resource的metadata | ||||
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 | ||||
language | 0..1 | code | 用以表述Procedure Resource內容的語言。 Binding: CommonLanguages (preferred): 人類語言;鼓勵使用CommonLanguages代碼表中的代碼,但不強制一定要使用此代碼表,你也可使用其他代碼表的代碼或單純以文字表示。
Example Value: zh-TW | |||||
text | 0..1 | Narrative | Procedure Resource之內容摘要以供人閱讀 | |||||
contained | 0..* | Resource | 內嵌的(contained)、行內的Resources | |||||
extension | 0..* | Extension | 擴充的資料項目 | |||||
modifierExtension | ?! | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 | ||||
identifier | SΣ | 1..* | Identifier | 此處置/手術的外部識別碼。[應填入門診病歷項次Item] | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
system | SΣ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | SΣ | 1..1 | string | The value that is unique Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | 實例化FHIR計畫書(protocol)或定義 | ||||
instantiatesUri | Σ | 0..* | uri | 實例化外部計畫書(protocol)或定義 | ||||
basedOn | Σ | 0..* | Reference(CarePlan | ServiceRequest) | 此Procedure是基於什麼而履行? | ||||
partOf | Σ | 0..* | Reference(TW Core Procedure | TW Core Observation Laboratory Result | MedicationAdministration) | 參照事件的一部分 | ||||
status | ?!SΣ | 1..1 | code | preparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknown Binding: EventStatus (required): 應填入所綁定值集中的其中一個代碼 Fixed Value: completed | ||||
statusReason | 0..1 | CodeableConceptTW | 當前狀態的原因。 Binding: ProcedureNotPerformedReason(SNOMED-CT) (extensible): 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。 | |||||
category | 0..1 | CodeableConceptTW | 處置/手術的分類。 Binding: ProcedureCategoryCodes(SNOMEDCT) (extensible): 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。 | |||||
code | S | 1..1 | CodeableConceptTW | 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] Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . | ||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 Slice: Unordered, Open by value:url | |||||
Slices for coding | S | 0..* | CodingTW | 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。 Slice: Unordered, Open by pattern:$this | ||||
coding:icd10-pcs-2021 | S | 0..1 | CodingTW | 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。 Binding: 臺灣健保署2021年中文版ICD-10-PCS值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:icd10-pcs-2014 | S | 0..1 | CodingTW | 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。 Binding: 臺灣健保署2014年中文版ICD-10-PCS值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:icd9-cm-2001 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required) | ||||
coding:medical-service-payment | S | 0..1 | CodingTW | 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。 Binding: 臺灣衛福部統計處藥品使用頻率值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:sct-procedures | S | 0..1 | CodingTW | 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。 Binding: ProcedureCodes(SNOMEDCT) (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
text | SΣ | 0..1 | string | 概念的文字表示法 | ||||
subject | SΣ | 1..1 | Reference(門診病歷-病人基本資料) | 誰有此病情、問題或診斷? | ||||
encounter | Σ | 0..1 | Reference(TW Core Encounter) | 就醫(Encounter)紀錄作為處置/手術的一部分 | ||||
performed[x] | SΣ | 0..1 | 此處置/手術何時執行的? | |||||
performedDateTime | dateTime S | |||||||
performedPeriod | Period | |||||||
performedString | string | |||||||
performedAge | Age | |||||||
performedRange | Range | |||||||
recorder | Σ | 0..1 | Reference(TW Core Patient | TW Core Practitioner | TW Core PractitionerRole | RelatedPerson) | 誰記錄此處置/手術 | ||||
asserter | SΣ | 0..1 | Reference(TW Core Patient | RelatedPerson | TW Core Practitioner | TW Core PractitionerRole) | 聲稱有此處置/手術的人 | ||||
performer | SΣ | 0..* | BackboneElement | 執行處置/手術的人員 | ||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 | |||||
modifierExtension | ?!Σ | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 | ||||
function | 0..1 | CodeableConceptTW | 執行的型別 Binding: ProcedurePerformerRoleCodes (extensible): 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。 | |||||
actor | SΣ | 1..1 | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | TW Core Patient | RelatedPerson | Device) | 參照至健康照護服務提供者 | ||||
onBehalfOf | S | 0..1 | Reference(TW Core Organization) | 此裝置(Device)或健康照護服務提供者所屬機構(Organization) | ||||
location | Σ | 0..1 | Reference(TW Core Location) | 處置/手術發生的地點(Location)? | ||||
reasonCode | 0..* | CodeableConceptTW | 處置/手術執行原因代碼 Binding: ProcedureReasonCodes (extensible): 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。 | |||||
reasonReference | Σ | 0..* | Reference(TW Core Condition | TW Core Observation Laboratory Result | TW Core Procedure | DiagnosticReport | DocumentReference) | 執行此處置/手術的原因 | ||||
bodySite | S | 0..* | CodeableConceptTW | 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] Binding: SNOMEDCTBodyStructures (extensible): 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。 | ||||
outcome | 0..1 | CodeableConceptTW | 處置/手術的結果。 Binding: ProcedureOutcomeCodes(SNOMEDCT) (extensible): 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。 | |||||
report | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | 此處置/手術產生的任何報告 | |||||
complication | 0..* | CodeableConceptTW | 處置/手術後的併發症 Binding: Condition/Problem/DiagnosisCodes (extensible): 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。 | |||||
complicationDetail | 0..* | Reference(TW Core Condition) | 處置/手術後發生的病情、問題或診斷 | |||||
followUp | S | 3..* | CodeableConceptTW | 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] Binding: ProcedureFollowUpCodes(SNOMEDCT) (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
note | S | 0..* | Annotation | 關於此處置/手術的附加資訊 | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
author[x] | Σ | 0..1 | Individual responsible for the annotation | |||||
authorReference | Reference(Practitioner | Patient | RelatedPerson | Organization) | |||||||
authorString | string | |||||||
time | Σ | 0..1 | dateTime | When the annotation was made | ||||
text | SΣ | 1..1 | markdown | The annotation - text content (as markdown)。[應填入於門診病歷註記或自費註記 Note/Self-pay note] | ||||
focalDevice | 0..* | BackboneElement | 處理、植入的或移除的裝置 | |||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 | |||||
modifierExtension | ?!Σ | 0..* | Extension | 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。 | ||||
action | 0..1 | CodeableConceptTW | 改變裝置的種類 Binding: ProcedureDeviceActionCodes (preferred): 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。 | |||||
manipulated | 1..1 | Reference(Device) | 被改變的裝置 | |||||
usedReference | 0..* | Reference(Device | Medication | Substance) | 處置/手術中使用的項目/物品 | |||||
usedCode | 0..* | CodeableConceptTW | 處置/手術中使用的項目之代碼 Binding: FHIRDeviceTypes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Procedure.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
Procedure.identifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | ||||
Procedure.status | required | Fixed Value: completedhttp://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard | ||||
Procedure.statusReason | extensible | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard | ||||
Procedure.category | extensible | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard | ||||
Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | ||||
Procedure.code.coding:icd10-pcs-2021 | required | TW2021ICD10PCShttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw | ||||
Procedure.code.coding:icd10-pcs-2014 | required | TW2014ICD10PCShttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2014-tw | ||||
Procedure.code.coding:icd9-cm-2001 | required | TW2001ICD9CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw | ||||
Procedure.code.coding:medical-service-payment | required | TWMedicationFrequencyhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/medication-frequency-tw | ||||
Procedure.code.coding:sct-procedures | required | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | ||||
Procedure.performer.function | extensible | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard | ||||
Procedure.reasonCode | extensible | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard | ||||
Procedure.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Procedure.outcome | extensible | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard | ||||
Procedure.complication | extensible | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Procedure.followUp | extensible | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard | ||||
Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-action from the FHIR Standard | ||||
Procedure.usedCode | extensible | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from TWCoreProcedure
Other representations of profile: CSV, Excel, Schematron