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
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:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 |
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 ele-1: All FHIR elements must have a @value or children |
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 |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Procedure.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | |
Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard | |
Procedure.category | extensible | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard | |
Procedure.category.coding | required | OrderType (a valid code from 醫令類別)https://www.ghd.tw/cdm-fhir/fhir/ValueSet/OrderType from this IG | |
Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | |
Procedure.code.coding:icd10-pcs-2023 | required | TW2023ICD10PCShttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2023-tw | |
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:medical-service-payment | required | TWMedicalServicePaymenthttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/procedure-tw | |
Procedure.code.coding:sct-procedures | required | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | |
Procedure.code.coding:loinc-procedures | required | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | |
Procedure.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site 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
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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] | |
subject | 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 | |
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] |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Procedure.category.coding | required | OrderType (a valid code from 醫令類別)https://www.ghd.tw/cdm-fhir/fhir/ValueSet/OrderType from this IG |
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 | 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。 | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Procedure.language | preferred | CommonLanguageshttp://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 | EventStatushttp://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.category.coding | required | OrderType (a valid code from 醫令類別)https://www.ghd.tw/cdm-fhir/fhir/ValueSet/OrderType from this IG | ||||
Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | ||||
Procedure.code.coding:icd10-pcs-2023 | required | TW2023ICD10PCShttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2023-tw | ||||
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:medical-service-payment | required | TWMedicalServicePaymenthttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/procedure-tw | ||||
Procedure.code.coding:sct-procedures | required | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | ||||
Procedure.code.coding:loinc-procedures | required | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | ||||
Procedure.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types 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
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:
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 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 |
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 ele-1: All FHIR elements must have a @value or children |
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 |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Procedure.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | |
Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard | |
Procedure.category | extensible | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard | |
Procedure.category.coding | required | OrderType (a valid code from 醫令類別)https://www.ghd.tw/cdm-fhir/fhir/ValueSet/OrderType from this IG | |
Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | |
Procedure.code.coding:icd10-pcs-2023 | required | TW2023ICD10PCShttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2023-tw | |
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:medical-service-payment | required | TWMedicalServicePaymenthttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/procedure-tw | |
Procedure.code.coding:sct-procedures | required | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | |
Procedure.code.coding:loinc-procedures | required | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | |
Procedure.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site 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() |
Differential View
This structure is derived from TWCoreProcedure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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] | |
subject | 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 | |
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] |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Procedure.category.coding | required | OrderType (a valid code from 醫令類別)https://www.ghd.tw/cdm-fhir/fhir/ValueSet/OrderType from this IG |
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 | 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。 | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Procedure.language | preferred | CommonLanguageshttp://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 | EventStatushttp://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.category.coding | required | OrderType (a valid code from 醫令類別)https://www.ghd.tw/cdm-fhir/fhir/ValueSet/OrderType from this IG | ||||
Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | ||||
Procedure.code.coding:icd10-pcs-2023 | required | TW2023ICD10PCShttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2023-tw | ||||
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:medical-service-payment | required | TWMedicalServicePaymenthttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/procedure-tw | ||||
Procedure.code.coding:sct-procedures | required | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | ||||
Procedure.code.coding:loinc-procedures | required | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | ||||
Procedure.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types 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
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:
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