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)
1.0.0 - ci-build

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) (v1.0.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Resource Profile: Procedure TOTFA、TOTFB-特定治療項目代號與手術(處置)代碼

Official URL: https://www.ghd.tw/cdm-fhir/StructureDefinition/ProcedureTOTFAB Version: 1.0.0
Active as of 2024-09-01 Computable Name: ProcedureTOTFAB

此Profile用於描述門診醫療申報檔(TOTFA)與住院醫療申報檔案(TOTFB)中的特定治療項目代號與手術(處置)代碼。

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
... 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
.... 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 特定治療項目代碼或手術(處置)代碼。對應至TOTFA:[TOTFA.d4/TOTFA.d5/TOTFA.d6/TOTFA.d7/TOTFA.d24/TOTFA.d25/TOTFA.d26]。對應至TOTFB:[TOTFB.d45/TOTFB.d46/TOTFB.d47/TOTFB.d48/TOTFB.d49]。或可由此補充說明此代碼用途,例如:特定治療項目代號(一)
ele-1: All FHIR elements must have a @value or children
... subject SΣ 1..1 Reference(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
... encounter SΣ 1..1 Reference(Encounter TOTFA-案件分類 | Encounter TOTFB-案件分類) 就醫(Encounter)紀錄作為處置/手術的一部分
ele-1: All FHIR elements must have a @value or children
.... reference SΣC 0..1 string Literal reference, Relative, internal or absolute URL
ele-1: All FHIR elements must have a @value or children
... performed[x] SΣ 0..1 此處置/手術何時執行的?
ele-1: All FHIR elements must have a @value or children
.... performedDateTime dateTime
... 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 1..1 Annotation 可補充說明此資料用途。備註特定治療項目代碼或手術(處置)代碼
ele-1: All FHIR elements must have a @value or children
.... text SΣ 1..1 markdown The annotation - text content (as markdown)
ele-1: All FHIR elements must have a @value or children
Example Example: 特定治療項目代號(一)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Procedure.statusrequiredEventStatus
http://hl7.org/fhir/ValueSet/event-status|4.0.1
from the FHIR Standard
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()

 

Other representations of profile: CSV, Excel, Schematron