醫查實作指引 - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
Official URL: https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/DischargeSummaryModel | Version: 0.1.0 | |||
Active as of 2024-08-12 | Computable Name: DischargeSummaryModel |
出院病摘(DischargeSummary)之資料模型
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Base
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DischargeSummaryModel | 0..* | Base | 出院病摘(DischargeSummary)之資料模型 Instances of this logical model are not marked to be the target of a Reference | |
organization | 1..1 | BackboneElement | 醫事機構 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
identifier | 1..1 | Identifier | 醫事機構代碼 | |
name | 1..1 | string | 醫事機構名稱 | |
patient | 1..1 | BackboneElement | 病人的基本資料 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
identifier | 1..1 | Identifier | 身分證字號 | |
patientNo | 1..1 | Identifier | 病歷號碼 | |
name | 1..* | HumanName | 姓名 | |
gender | 1..1 | CodeableConcept | 性別 | |
birthDate | 1..1 | dateTime | 出生日期 | |
hospitalizedInformation | 1..1 | BackboneElement | 住院的基本資料 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
department | 1..1 | CodeableConcept | 出院科別 | |
bedNo | 1..1 | Identifier | 出院床號 | |
dateofHospitalization | 1..1 | dateTime | 住院日期 | |
dischargeDate | 1..1 | dateTime | 出院日期 | |
impression | 0..* | BackboneElement | 住院臆斷 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
impressionCode | 1..1 | CodeableConcept | 住院臆斷代碼 | |
impressionValue | 0..1 | string | 住院臆斷實際值 | |
impressionDate | 0..1 | dateTime | 住院臆斷日期 | |
dischargeDiagnosis | 1..* | BackboneElement | 出院診斷 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
dischargeDiagnosisCode | 1..1 | CodeableConcept | 出院診斷代碼 | |
dischargeDiagnosisDate | 0..1 | dateTime | 出院診斷日期 | |
cancerStaging | 0..1 | BackboneElement | 癌症期別 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
cancerStagingCode | 1..1 | CodeableConcept | 癌症期別代碼 | |
cancerStagingValue | 0..1 | CodeableConcept | 癌症期別實際值 | |
cancerStagingDate | 0..1 | dateTime | 癌症期別日期 | |
chiefComplaint | 1..1 | BackboneElement | 主訴 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
chiefComplaintValue | 1..1 | Annotation | 主訴實際值 | |
presentIllness | 0..* | BackboneElement | 病史 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
presentIllnessCode | 1..1 | CodeableConcept | 病史代碼 | |
physicalExamination | 0..* | BackboneElement | 理學檢查發現 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
physicalExaminationCode | 1..1 | CodeableConcept | 理學檢查發現代碼 | |
physicalExaminationValue | 0..1 | string | 理學檢查發現實際值 | |
physicalExaminationDate | 0..1 | dateTime | 理學檢查發現日期 | |
laboratoryData | 0..* | BackboneElement | 檢驗 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
laboratoryDataCode | 1..1 | CodeableConcept | 檢驗代碼 | |
laboratoryDataValue | 0..1 | string | 檢驗實際值 | |
laboratoryDataDate | 0..1 | dateTime | 檢驗日期 | |
specificExamination | 0..* | BackboneElement | 特殊檢查 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
specificExaminationCode | 1..1 | CodeableConcept | 特殊檢查代碼 | |
specificExaminationValue | 0..1 | string | 特殊檢查實際值 | |
specificExaminationDate | 0..1 | dateTime | 特殊檢查日期 | |
imagingStudy | 0..* | BackboneElement | 醫療影像檢查 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
imagingStudyDescription | 0..1 | string | 醫療影像檢查敘述 | |
imagingStudyInterpreter | 0..* | HumanName | 醫療影像檢查解讀者 | |
imagingStudyDate | 1..1 | dateTime | 醫療影像檢查開始時間 | |
pathologyReport | 0..* | BackboneElement | 病理報告 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
pathologyReportCode | 1..1 | CodeableConcept | 病理報告代碼 | |
pathologyReportValue | 0..1 | string | 病理報告實際值 | |
pathologyReportDate | 0..1 | dateTime | 病理報告日期 | |
surgicalMethod | 1..* | BackboneElement | 手術日期及方法 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
surgicalMethodCode | 1..1 | CodeableConcept | 手術方法 | |
surgicalMethodDate | 1..1 | dateTime | 手術日期 | |
hospitalCourse | 1..1 | BackboneElement | 住院治療經過 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
hospitalCourseCode | 1..1 | CodeableConcept | 住院治療經過代碼 | |
hospitalCourseValue | 1..1 | markdown | 住院治療經過實際值 | |
comorbiditesAndOrComlications | 0..* | BackboneElement | 合併症與併發症 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
comorbiditesAndOrComlicationsCode | 1..1 | CodeableConcept | 合併症與併發症代碼 | |
comorbiditesAndOrComlicationsDate | 0..1 | dateTime | 合併症與併發症日期 | |
instructionsOnDischarge | 1..1 | BackboneElement | 出院指示 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
instructionsOnDischargeDescription | 0..1 | string | 出院指示敘述 | |
instructionsOnDischargeMedication | 1..1 | CodeableConcept | 出院指示藥品 | |
dischargeStatus | 1..1 | CodeableConcept | 出院狀況 | |
physicianName | 1..* | HumanName | 醫師姓名 | |
Documentation for this format |
This structure is derived from Base
Differential View
This structure is derived from Base
Key Elements View
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DischargeSummaryModel | 0..* | Base | 出院病摘(DischargeSummary)之資料模型 Instances of this logical model are not marked to be the target of a Reference | |
organization | 1..1 | BackboneElement | 醫事機構 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
identifier | 1..1 | Identifier | 醫事機構代碼 | |
name | 1..1 | string | 醫事機構名稱 | |
patient | 1..1 | BackboneElement | 病人的基本資料 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
identifier | 1..1 | Identifier | 身分證字號 | |
patientNo | 1..1 | Identifier | 病歷號碼 | |
name | 1..* | HumanName | 姓名 | |
gender | 1..1 | CodeableConcept | 性別 | |
birthDate | 1..1 | dateTime | 出生日期 | |
hospitalizedInformation | 1..1 | BackboneElement | 住院的基本資料 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
department | 1..1 | CodeableConcept | 出院科別 | |
bedNo | 1..1 | Identifier | 出院床號 | |
dateofHospitalization | 1..1 | dateTime | 住院日期 | |
dischargeDate | 1..1 | dateTime | 出院日期 | |
impression | 0..* | BackboneElement | 住院臆斷 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
impressionCode | 1..1 | CodeableConcept | 住院臆斷代碼 | |
impressionValue | 0..1 | string | 住院臆斷實際值 | |
impressionDate | 0..1 | dateTime | 住院臆斷日期 | |
dischargeDiagnosis | 1..* | BackboneElement | 出院診斷 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
dischargeDiagnosisCode | 1..1 | CodeableConcept | 出院診斷代碼 | |
dischargeDiagnosisDate | 0..1 | dateTime | 出院診斷日期 | |
cancerStaging | 0..1 | BackboneElement | 癌症期別 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
cancerStagingCode | 1..1 | CodeableConcept | 癌症期別代碼 | |
cancerStagingValue | 0..1 | CodeableConcept | 癌症期別實際值 | |
cancerStagingDate | 0..1 | dateTime | 癌症期別日期 | |
chiefComplaint | 1..1 | BackboneElement | 主訴 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
chiefComplaintValue | 1..1 | Annotation | 主訴實際值 | |
presentIllness | 0..* | BackboneElement | 病史 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
presentIllnessCode | 1..1 | CodeableConcept | 病史代碼 | |
physicalExamination | 0..* | BackboneElement | 理學檢查發現 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
physicalExaminationCode | 1..1 | CodeableConcept | 理學檢查發現代碼 | |
physicalExaminationValue | 0..1 | string | 理學檢查發現實際值 | |
physicalExaminationDate | 0..1 | dateTime | 理學檢查發現日期 | |
laboratoryData | 0..* | BackboneElement | 檢驗 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
laboratoryDataCode | 1..1 | CodeableConcept | 檢驗代碼 | |
laboratoryDataValue | 0..1 | string | 檢驗實際值 | |
laboratoryDataDate | 0..1 | dateTime | 檢驗日期 | |
specificExamination | 0..* | BackboneElement | 特殊檢查 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
specificExaminationCode | 1..1 | CodeableConcept | 特殊檢查代碼 | |
specificExaminationValue | 0..1 | string | 特殊檢查實際值 | |
specificExaminationDate | 0..1 | dateTime | 特殊檢查日期 | |
imagingStudy | 0..* | BackboneElement | 醫療影像檢查 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
imagingStudyDescription | 0..1 | string | 醫療影像檢查敘述 | |
imagingStudyInterpreter | 0..* | HumanName | 醫療影像檢查解讀者 | |
imagingStudyDate | 1..1 | dateTime | 醫療影像檢查開始時間 | |
pathologyReport | 0..* | BackboneElement | 病理報告 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
pathologyReportCode | 1..1 | CodeableConcept | 病理報告代碼 | |
pathologyReportValue | 0..1 | string | 病理報告實際值 | |
pathologyReportDate | 0..1 | dateTime | 病理報告日期 | |
surgicalMethod | 1..* | BackboneElement | 手術日期及方法 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
surgicalMethodCode | 1..1 | CodeableConcept | 手術方法 | |
surgicalMethodDate | 1..1 | dateTime | 手術日期 | |
hospitalCourse | 1..1 | BackboneElement | 住院治療經過 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
hospitalCourseCode | 1..1 | CodeableConcept | 住院治療經過代碼 | |
hospitalCourseValue | 1..1 | markdown | 住院治療經過實際值 | |
comorbiditesAndOrComlications | 0..* | BackboneElement | 合併症與併發症 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
comorbiditesAndOrComlicationsCode | 1..1 | CodeableConcept | 合併症與併發症代碼 | |
comorbiditesAndOrComlicationsDate | 0..1 | dateTime | 合併症與併發症日期 | |
instructionsOnDischarge | 1..1 | BackboneElement | 出院指示 | |
@id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
instructionsOnDischargeDescription | 0..1 | string | 出院指示敘述 | |
instructionsOnDischargeMedication | 1..1 | CodeableConcept | 出院指示藥品 | |
dischargeStatus | 1..1 | CodeableConcept | 出院狀況 | |
physicianName | 1..* | HumanName | 醫師姓名 | |
Documentation for this format |
This structure is derived from Base