國家級人體生物資料庫整合平台共同資料模式實作指引(NBCT Common Data Model IG)
0.1.0 - trial-use

This page is part of the 國家級人體生物資料庫整合平台共同資料模式實作指引(NBCT Common Data Model 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: Procedure 醫令清單段

Official URL: https://www.ghd.tw/cdm-fhir/fhir/StructureDefinition/ProcedureCDMorder Version: 0.1.0
Active as of 2024-09-01 Computable Name: ProcedureCDMorder

用於描述檢驗報告相關之醫令清單段,門診醫療申報檔(TOTFA)、住院醫療申報檔案(TOTFB)與檢驗檢查資料檔每月格式(LABM)需視資料內容決定是否需要使用此Profile

Usage:

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..* TWCoreProcedure 正在或曾經對病人執行的動作
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
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
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
... implicitRules ?!Σ 0..1 uri 創建此內容所依據的一組規則
ele-1: All FHIR elements must have a @value or children
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... identifier SΣ 1..1 Identifier 此處置/手術的外部識別碼
ele-1: All FHIR elements must have a @value or children
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


ele-1: All FHIR elements must have a @value or children
.... system SΣ 0..1 uri The namespace for the identifier value
ele-1: All FHIR elements must have a @value or children
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string 醫令序。[TOTFA.p13/TOTFB.p1/LABM.h17]
ele-1: All FHIR elements must have a @value or children
Example General: 123456
... category S 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。


ele-1: All FHIR elements must have a @value or children
.... coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 醫令類別值集 (required): 醫令類別;應填入所綁定值集中的其中一個代碼。


ele-1: All FHIR elements must have a @value or children
..... system SΣ 1..1 uri 專門術語系統(terminology system)的識別
ele-1: All FHIR elements must have a @value or children
..... code SΣ 1..1 code 醫令類別之代碼。[TOTFA.p3/TOTFB.p2]
ele-1: All FHIR elements must have a @value or children
..... display SΣ 0..1 string 由系統定義的表示法
ele-1: All FHIR elements must have a @value or children
.... text SΣ 0..1 string 醫令類別。[TOTFA.p3/TOTFB.p2]
ele-1: All FHIR elements must have a @value or children
... code S 1..1 CodeableConceptTW 醫令代碼,[TOTFB.p3/LABM.h18]
Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure .


ele-1: All FHIR elements must have a @value or children
.... 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
ele-1: All FHIR elements must have a @value or children
..... coding:icd10-pcs-2023 S 0..1 CodingTW 此為臺灣衛生福利部中央健康保險署(NHI)維護之2023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2023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。


ele-1: All FHIR elements must have a @value or children
..... 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。


ele-1: All FHIR elements must have a @value or children
..... 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。


ele-1: All FHIR elements must have a @value or children
..... 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: 臺灣健保署醫療服務給付項目-處置或手術值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。


ele-1: All FHIR elements must have a @value or children
..... 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。


ele-1: All FHIR elements must have a @value or children
..... coding:loinc-procedures S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: LOINCCodes (required)
ele-1: All FHIR elements must have a @value or children
.... text SΣ 0..1 string 醫令代碼。[TOTFB.p3/LABM.h18]
ele-1: All FHIR elements must have a @value or children
... subject SΣ 1..1 Reference(TW Core Patient | Patient TOTFA、TOTFB、LABD、LAM、CASE-病患基本資料) 處置/手術服務的對象
ele-1: All FHIR elements must have a @value or children
.... reference SΣC 1..1 string 患者Resource Link
ele-1: All FHIR elements must have a @value or children
... Slices for performed[x] SΣ 0..1 執行時間
Slice: Unordered, Open by type:$this
ele-1: All FHIR elements must have a @value or children
.... performedDateTime dateTime
.... performed[x]:performedPeriod SΣ 0..1 Period 此處置/手術何時執行的?
ele-1: All FHIR elements must have a @value or children
..... start SΣC 1..1 dateTime 執行時間-起。[TOTFA.p14/TOTFB.p14]
ele-1: All FHIR elements must have a @value or children
..... end SΣC 0..1 dateTime 執行時間-迄。[TOTFA.p15/TOTFB.p15]
ele-1: All FHIR elements must have a @value or children
... asserter SΣ 0..1 Reference(TW Core Patient | TW Core RelatedPerson | TW Core Practitioner | TW Core PractitionerRole) 聲稱有此處置/手術的人
ele-1: All FHIR elements must have a @value or children
... performer SΣ 0..* BackboneElement 執行處置/手術的人員
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... actor SΣ 1..1 Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | TW Core Patient | TW Core RelatedPerson | Device) 參照至健康照護服務提供者
ele-1: All FHIR elements must have a @value or children
.... 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)
ele-1: All FHIR elements must have a @value or children
... bodySite S 0..* CodeableConceptTW 目標身體部位。
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。


ele-1: All FHIR elements must have a @value or children
... note S 0..* Annotation 關於此處置/手術的附加資訊
ele-1: All FHIR elements must have a @value or children
.... text SΣ 1..1 markdown 會診科別、總量或其他補充說明。[TOTFA.p10/TOTFB.p8/TOTFB.p16]
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Procedure.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Procedure.statusrequiredEventStatus
http://hl7.org/fhir/ValueSet/event-status|4.0.1
from the FHIR Standard
Procedure.categoryextensibleProcedureCategoryCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-category
from the FHIR Standard
Procedure.category.codingrequiredOrderType (a valid code from 醫令類別)
https://www.ghd.tw/cdm-fhir/fhir/ValueSet/OrderType
from this IG
Procedure.codeexampleProcedureCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-code
from the FHIR Standard
Procedure.code.coding:icd10-pcs-2023requiredTW2023ICD10PCS
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2023-tw
Procedure.code.coding:icd10-pcs-2021requiredTW2021ICD10PCS
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw
Procedure.code.coding:icd10-pcs-2014requiredTW2014ICD10PCS
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2014-tw
Procedure.code.coding:medical-service-paymentrequiredTWMedicalServicePayment
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/procedure-tw
Procedure.code.coding:sct-proceduresrequiredProcedureCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-code
from the FHIR Standard
Procedure.code.coding:loinc-proceduresrequiredLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Procedure.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from TWCoreProcedure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure TWCoreProcedure
... identifier S 1..1 Identifier 此處置/手術的外部識別碼
.... system S 0..1 uri The namespace for the identifier value
.... value S 1..1 string 醫令序。[TOTFA.p13/TOTFB.p1/LABM.h17]
... category S 0..1 CodeableConceptTW 處置/手術的分類。
.... coding 0..* CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 醫令類別值集 (required): 醫令類別;應填入所綁定值集中的其中一個代碼。

..... system 1..1 uri 專門術語系統(terminology system)的識別
..... code 1..1 code 醫令類別之代碼。[TOTFA.p3/TOTFB.p2]
.... text 0..1 string 醫令類別。[TOTFA.p3/TOTFB.p2]
... code 1..1 CodeableConceptTW 醫令代碼,[TOTFB.p3/LABM.h18]
.... text 0..1 string 醫令代碼。[TOTFB.p3/LABM.h18]
.... reference S 1..1 string 患者Resource Link
... Slices for performed[x] 0..1 dateTime, Period, string, Age, Range 執行時間
Slice: Unordered, Open by type:$this
.... performed[x]:performedPeriod 0..1 Period 此處置/手術何時執行的?
..... start S 1..1 dateTime 執行時間-起。[TOTFA.p14/TOTFB.p14]
..... end S 0..1 dateTime 執行時間-迄。[TOTFA.p15/TOTFB.p15]
... note S 0..* Annotation 關於此處置/手術的附加資訊
.... text S 1..1 markdown 會診科別、總量或其他補充說明。[TOTFA.p10/TOTFB.p8/TOTFB.p16]

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Procedure.category.codingrequiredOrderType (a valid code from 醫令類別)
https://www.ghd.tw/cdm-fhir/fhir/ValueSet/OrderType
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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。

Additional BindingsPurpose
AllLanguages Max Binding

Example Value: zh-TW
... text 0..1 Narrative Procedure Resource之內容摘要以供人閱讀
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier 此處置/手術的外部識別碼
.... 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 醫令序。[TOTFA.p13/TOTFB.p1/LABM.h17]
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

... 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 S 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。

.... id 0..1 string 唯一可識別ID,以供資料項目間相互參照。
.... extension 0..* Extension 擴充的資料項目
Slice: Unordered, Open by value:url
.... coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 醫令類別值集 (required): 醫令類別;應填入所綁定值集中的其中一個代碼。


..... id 0..1 string 唯一可識別ID,以供資料項目間相互參照。
..... extension 0..* Extension 擴充的資料項目
Slice: Unordered, Open by value:url
..... system SΣ 1..1 uri 專門術語系統(terminology system)的識別
..... version Σ 0..1 string 系統的版本—如果相關的話
..... code SΣ 1..1 code 醫令類別之代碼。[TOTFA.p3/TOTFB.p2]
..... display SΣ 0..1 string 由系統定義的表示法
..... userSelected Σ 0..1 boolean 此編碼是否由使用者直接選擇?
.... text SΣ 0..1 string 醫令類別。[TOTFA.p3/TOTFB.p2]
... code S 1..1 CodeableConceptTW 醫令代碼,[TOTFB.p3/LABM.h18]
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-2023 S 0..1 CodingTW 此為臺灣衛生福利部中央健康保險署(NHI)維護之2023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2023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-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: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: 臺灣健保署醫療服務給付項目-處置或手術值集 (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。


..... coding:loinc-procedures S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: LOINCCodes (required)
.... text SΣ 0..1 string 醫令代碼。[TOTFB.p3/LABM.h18]
... subject SΣ 1..1 Reference(TW Core Patient | Patient TOTFA、TOTFB、LABD、LAM、CASE-病患基本資料) 處置/手術服務的對象
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string 患者Resource Link
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... encounter Σ 0..1 Reference(TW Core Encounter) 就醫(Encounter)紀錄作為處置/手術的一部分
... Slices for performed[x] SΣ 0..1 執行時間
Slice: Unordered, Open by type:$this
.... performedDateTime dateTime S
.... performedPeriod Period
.... performedString string
.... performedAge Age
.... performedRange Range
.... performed[x]:performedPeriod SΣ 0..1 Period 此處置/手術何時執行的?
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... start SΣC 1..1 dateTime 執行時間-起。[TOTFA.p14/TOTFB.p14]
..... end SΣC 0..1 dateTime 執行時間-迄。[TOTFA.p15/TOTFB.p15]
... recorder Σ 0..1 Reference(TW Core Patient | TW Core Practitioner | TW Core PractitionerRole | TW Core RelatedPerson) 誰記錄此處置/手術
... asserter SΣ 0..1 Reference(TW Core Patient | TW Core 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 Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... 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 | TW Core 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。
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 0..* CodeableConceptTW 追蹤說明。
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 會診科別、總量或其他補充說明。[TOTFA.p10/TOTFB.p8/TOTFB.p16]
... focalDevice 0..* BackboneElement 處理、植入的或移除的裝置
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... 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。



doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Procedure.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Procedure.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Procedure.identifier.typeextensibleIdentifier Type Codes
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Procedure.statusrequiredEventStatus
http://hl7.org/fhir/ValueSet/event-status|4.0.1
from the FHIR Standard
Procedure.statusReasonextensibleProcedureNotPerformedReason(SNOMED-CT)
http://hl7.org/fhir/ValueSet/procedure-not-performed-reason
from the FHIR Standard
Procedure.categoryextensibleProcedureCategoryCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-category
from the FHIR Standard
Procedure.category.codingrequiredOrderType (a valid code from 醫令類別)
https://www.ghd.tw/cdm-fhir/fhir/ValueSet/OrderType
from this IG
Procedure.codeexampleProcedureCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-code
from the FHIR Standard
Procedure.code.coding:icd10-pcs-2023requiredTW2023ICD10PCS
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2023-tw
Procedure.code.coding:icd10-pcs-2021requiredTW2021ICD10PCS
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw
Procedure.code.coding:icd10-pcs-2014requiredTW2014ICD10PCS
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2014-tw
Procedure.code.coding:medical-service-paymentrequiredTWMedicalServicePayment
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/procedure-tw
Procedure.code.coding:sct-proceduresrequiredProcedureCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-code
from the FHIR Standard
Procedure.code.coding:loinc-proceduresrequiredLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Procedure.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Procedure.performer.functionextensibleProcedurePerformerRoleCodes
http://hl7.org/fhir/ValueSet/performer-role
from the FHIR Standard
Procedure.reasonCodeextensibleProcedureReasonCodes
http://hl7.org/fhir/ValueSet/procedure-reason
from the FHIR Standard
Procedure.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Procedure.outcomeextensibleProcedureOutcomeCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-outcome
from the FHIR Standard
Procedure.complicationextensibleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Procedure.followUpextensibleProcedureFollowUpCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-followup
from the FHIR Standard
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
http://hl7.org/fhir/ValueSet/device-action
from the FHIR Standard
Procedure.usedCodeextensibleFHIRDeviceTypes
http://hl7.org/fhir/ValueSet/device-kind
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from TWCoreProcedure

Summary

Mandatory: 3 elements(3 nested mandatory elements)
Must-Support: 9 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Procedure.performed[x]

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..* TWCoreProcedure 正在或曾經對病人執行的動作
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
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
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
... implicitRules ?!Σ 0..1 uri 創建此內容所依據的一組規則
ele-1: All FHIR elements must have a @value or children
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... identifier SΣ 1..1 Identifier 此處置/手術的外部識別碼
ele-1: All FHIR elements must have a @value or children
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


ele-1: All FHIR elements must have a @value or children
.... system SΣ 0..1 uri The namespace for the identifier value
ele-1: All FHIR elements must have a @value or children
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string 醫令序。[TOTFA.p13/TOTFB.p1/LABM.h17]
ele-1: All FHIR elements must have a @value or children
Example General: 123456
... category S 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。


ele-1: All FHIR elements must have a @value or children
.... coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 醫令類別值集 (required): 醫令類別;應填入所綁定值集中的其中一個代碼。


ele-1: All FHIR elements must have a @value or children
..... system SΣ 1..1 uri 專門術語系統(terminology system)的識別
ele-1: All FHIR elements must have a @value or children
..... code SΣ 1..1 code 醫令類別之代碼。[TOTFA.p3/TOTFB.p2]
ele-1: All FHIR elements must have a @value or children
..... display SΣ 0..1 string 由系統定義的表示法
ele-1: All FHIR elements must have a @value or children
.... text SΣ 0..1 string 醫令類別。[TOTFA.p3/TOTFB.p2]
ele-1: All FHIR elements must have a @value or children
... code S 1..1 CodeableConceptTW 醫令代碼,[TOTFB.p3/LABM.h18]
Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure .


ele-1: All FHIR elements must have a @value or children
.... 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
ele-1: All FHIR elements must have a @value or children
..... coding:icd10-pcs-2023 S 0..1 CodingTW 此為臺灣衛生福利部中央健康保險署(NHI)維護之2023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2023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。


ele-1: All FHIR elements must have a @value or children
..... 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。


ele-1: All FHIR elements must have a @value or children
..... 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。


ele-1: All FHIR elements must have a @value or children
..... 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: 臺灣健保署醫療服務給付項目-處置或手術值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。


ele-1: All FHIR elements must have a @value or children
..... 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。


ele-1: All FHIR elements must have a @value or children
..... coding:loinc-procedures S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: LOINCCodes (required)
ele-1: All FHIR elements must have a @value or children
.... text SΣ 0..1 string 醫令代碼。[TOTFB.p3/LABM.h18]
ele-1: All FHIR elements must have a @value or children
... subject SΣ 1..1 Reference(TW Core Patient | Patient TOTFA、TOTFB、LABD、LAM、CASE-病患基本資料) 處置/手術服務的對象
ele-1: All FHIR elements must have a @value or children
.... reference SΣC 1..1 string 患者Resource Link
ele-1: All FHIR elements must have a @value or children
... Slices for performed[x] SΣ 0..1 執行時間
Slice: Unordered, Open by type:$this
ele-1: All FHIR elements must have a @value or children
.... performedDateTime dateTime
.... performed[x]:performedPeriod SΣ 0..1 Period 此處置/手術何時執行的?
ele-1: All FHIR elements must have a @value or children
..... start SΣC 1..1 dateTime 執行時間-起。[TOTFA.p14/TOTFB.p14]
ele-1: All FHIR elements must have a @value or children
..... end SΣC 0..1 dateTime 執行時間-迄。[TOTFA.p15/TOTFB.p15]
ele-1: All FHIR elements must have a @value or children
... asserter SΣ 0..1 Reference(TW Core Patient | TW Core RelatedPerson | TW Core Practitioner | TW Core PractitionerRole) 聲稱有此處置/手術的人
ele-1: All FHIR elements must have a @value or children
... performer SΣ 0..* BackboneElement 執行處置/手術的人員
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... actor SΣ 1..1 Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | TW Core Patient | TW Core RelatedPerson | Device) 參照至健康照護服務提供者
ele-1: All FHIR elements must have a @value or children
.... 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)
ele-1: All FHIR elements must have a @value or children
... bodySite S 0..* CodeableConceptTW 目標身體部位。
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。


ele-1: All FHIR elements must have a @value or children
... note S 0..* Annotation 關於此處置/手術的附加資訊
ele-1: All FHIR elements must have a @value or children
.... text SΣ 1..1 markdown 會診科別、總量或其他補充說明。[TOTFA.p10/TOTFB.p8/TOTFB.p16]
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Procedure.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Procedure.statusrequiredEventStatus
http://hl7.org/fhir/ValueSet/event-status|4.0.1
from the FHIR Standard
Procedure.categoryextensibleProcedureCategoryCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-category
from the FHIR Standard
Procedure.category.codingrequiredOrderType (a valid code from 醫令類別)
https://www.ghd.tw/cdm-fhir/fhir/ValueSet/OrderType
from this IG
Procedure.codeexampleProcedureCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-code
from the FHIR Standard
Procedure.code.coding:icd10-pcs-2023requiredTW2023ICD10PCS
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2023-tw
Procedure.code.coding:icd10-pcs-2021requiredTW2021ICD10PCS
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw
Procedure.code.coding:icd10-pcs-2014requiredTW2014ICD10PCS
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2014-tw
Procedure.code.coding:medical-service-paymentrequiredTWMedicalServicePayment
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/procedure-tw
Procedure.code.coding:sct-proceduresrequiredProcedureCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-code
from the FHIR Standard
Procedure.code.coding:loinc-proceduresrequiredLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Procedure.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from TWCoreProcedure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure TWCoreProcedure
... identifier S 1..1 Identifier 此處置/手術的外部識別碼
.... system S 0..1 uri The namespace for the identifier value
.... value S 1..1 string 醫令序。[TOTFA.p13/TOTFB.p1/LABM.h17]
... category S 0..1 CodeableConceptTW 處置/手術的分類。
.... coding 0..* CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 醫令類別值集 (required): 醫令類別;應填入所綁定值集中的其中一個代碼。

..... system 1..1 uri 專門術語系統(terminology system)的識別
..... code 1..1 code 醫令類別之代碼。[TOTFA.p3/TOTFB.p2]
.... text 0..1 string 醫令類別。[TOTFA.p3/TOTFB.p2]
... code 1..1 CodeableConceptTW 醫令代碼,[TOTFB.p3/LABM.h18]
.... text 0..1 string 醫令代碼。[TOTFB.p3/LABM.h18]
.... reference S 1..1 string 患者Resource Link
... Slices for performed[x] 0..1 dateTime, Period, string, Age, Range 執行時間
Slice: Unordered, Open by type:$this
.... performed[x]:performedPeriod 0..1 Period 此處置/手術何時執行的?
..... start S 1..1 dateTime 執行時間-起。[TOTFA.p14/TOTFB.p14]
..... end S 0..1 dateTime 執行時間-迄。[TOTFA.p15/TOTFB.p15]
... note S 0..* Annotation 關於此處置/手術的附加資訊
.... text S 1..1 markdown 會診科別、總量或其他補充說明。[TOTFA.p10/TOTFB.p8/TOTFB.p16]

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Procedure.category.codingrequiredOrderType (a valid code from 醫令類別)
https://www.ghd.tw/cdm-fhir/fhir/ValueSet/OrderType
from this IG

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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。

Additional BindingsPurpose
AllLanguages Max Binding

Example Value: zh-TW
... text 0..1 Narrative Procedure Resource之內容摘要以供人閱讀
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier 此處置/手術的外部識別碼
.... 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 醫令序。[TOTFA.p13/TOTFB.p1/LABM.h17]
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

... 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 S 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。

.... id 0..1 string 唯一可識別ID,以供資料項目間相互參照。
.... extension 0..* Extension 擴充的資料項目
Slice: Unordered, Open by value:url
.... coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 醫令類別值集 (required): 醫令類別;應填入所綁定值集中的其中一個代碼。


..... id 0..1 string 唯一可識別ID,以供資料項目間相互參照。
..... extension 0..* Extension 擴充的資料項目
Slice: Unordered, Open by value:url
..... system SΣ 1..1 uri 專門術語系統(terminology system)的識別
..... version Σ 0..1 string 系統的版本—如果相關的話
..... code SΣ 1..1 code 醫令類別之代碼。[TOTFA.p3/TOTFB.p2]
..... display SΣ 0..1 string 由系統定義的表示法
..... userSelected Σ 0..1 boolean 此編碼是否由使用者直接選擇?
.... text SΣ 0..1 string 醫令類別。[TOTFA.p3/TOTFB.p2]
... code S 1..1 CodeableConceptTW 醫令代碼,[TOTFB.p3/LABM.h18]
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-2023 S 0..1 CodingTW 此為臺灣衛生福利部中央健康保險署(NHI)維護之2023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2023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-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: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: 臺灣健保署醫療服務給付項目-處置或手術值集 (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。


..... coding:loinc-procedures S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: LOINCCodes (required)
.... text SΣ 0..1 string 醫令代碼。[TOTFB.p3/LABM.h18]
... subject SΣ 1..1 Reference(TW Core Patient | Patient TOTFA、TOTFB、LABD、LAM、CASE-病患基本資料) 處置/手術服務的對象
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string 患者Resource Link
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... encounter Σ 0..1 Reference(TW Core Encounter) 就醫(Encounter)紀錄作為處置/手術的一部分
... Slices for performed[x] SΣ 0..1 執行時間
Slice: Unordered, Open by type:$this
.... performedDateTime dateTime S
.... performedPeriod Period
.... performedString string
.... performedAge Age
.... performedRange Range
.... performed[x]:performedPeriod SΣ 0..1 Period 此處置/手術何時執行的?
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... start SΣC 1..1 dateTime 執行時間-起。[TOTFA.p14/TOTFB.p14]
..... end SΣC 0..1 dateTime 執行時間-迄。[TOTFA.p15/TOTFB.p15]
... recorder Σ 0..1 Reference(TW Core Patient | TW Core Practitioner | TW Core PractitionerRole | TW Core RelatedPerson) 誰記錄此處置/手術
... asserter SΣ 0..1 Reference(TW Core Patient | TW Core 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 Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... 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 | TW Core 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。
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 0..* CodeableConceptTW 追蹤說明。
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 會診科別、總量或其他補充說明。[TOTFA.p10/TOTFB.p8/TOTFB.p16]
... focalDevice 0..* BackboneElement 處理、植入的或移除的裝置
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... 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。



doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Procedure.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Procedure.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Procedure.identifier.typeextensibleIdentifier Type Codes
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Procedure.statusrequiredEventStatus
http://hl7.org/fhir/ValueSet/event-status|4.0.1
from the FHIR Standard
Procedure.statusReasonextensibleProcedureNotPerformedReason(SNOMED-CT)
http://hl7.org/fhir/ValueSet/procedure-not-performed-reason
from the FHIR Standard
Procedure.categoryextensibleProcedureCategoryCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-category
from the FHIR Standard
Procedure.category.codingrequiredOrderType (a valid code from 醫令類別)
https://www.ghd.tw/cdm-fhir/fhir/ValueSet/OrderType
from this IG
Procedure.codeexampleProcedureCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-code
from the FHIR Standard
Procedure.code.coding:icd10-pcs-2023requiredTW2023ICD10PCS
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2023-tw
Procedure.code.coding:icd10-pcs-2021requiredTW2021ICD10PCS
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw
Procedure.code.coding:icd10-pcs-2014requiredTW2014ICD10PCS
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2014-tw
Procedure.code.coding:medical-service-paymentrequiredTWMedicalServicePayment
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/procedure-tw
Procedure.code.coding:sct-proceduresrequiredProcedureCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-code
from the FHIR Standard
Procedure.code.coding:loinc-proceduresrequiredLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Procedure.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Procedure.performer.functionextensibleProcedurePerformerRoleCodes
http://hl7.org/fhir/ValueSet/performer-role
from the FHIR Standard
Procedure.reasonCodeextensibleProcedureReasonCodes
http://hl7.org/fhir/ValueSet/procedure-reason
from the FHIR Standard
Procedure.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Procedure.outcomeextensibleProcedureOutcomeCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-outcome
from the FHIR Standard
Procedure.complicationextensibleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Procedure.followUpextensibleProcedureFollowUpCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-followup
from the FHIR Standard
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
http://hl7.org/fhir/ValueSet/device-action
from the FHIR Standard
Procedure.usedCodeextensibleFHIRDeviceTypes
http://hl7.org/fhir/ValueSet/device-kind
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from TWCoreProcedure

Summary

Mandatory: 3 elements(3 nested mandatory elements)
Must-Support: 9 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Procedure.performed[x]

 

Other representations of profile: CSV, Excel, Schematron