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

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Resource Profile: CompositionOperationNote IMRI

此Profile用於描述手術紀錄的報告文件。

Usage:

• Use this Resource Profile: BundleOperationNote IMRI
• Refer to this Resource Profile: ProcedureAnesthesiaMode IMRI, Procedure IMRI and ProcedureHospitalCourse IMRI
• Examples for this Resource Profile: Composition/CompositionOperationNote-min

Formal Views of Profile Content

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

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from TWCoreComposition

Name	Flags	Card.	Type	Description & Constraints
Composition			TWCoreComposition
status		1..1	code	registered | partial | preliminary | final | amended | corrected + Required Pattern: final
type		1..1	CodeableConceptTW	Composition的種類（如果可能請使用LOINC） Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11504-8
display		1..1	string	Representation defined by the system Fixed Value: Surgical operation note
subject		1..1	Reference(Patient IMRI)	Composition是關於誰和/或什麼
encounter		0..1	Reference(Encounter IMRI)	Composition的情境
author		1..*	Reference(Organization Hospital Department IMRI | Practitioner IMRI)	誰和/或什麼創建了這個Composition
title		1..1	string	人類可讀的名稱/標題 Fixed Value: 手術紀錄
attester
party		0..1	Reference(Patient IMRI | RelatedPerson | Practitioner IMRI | PractitionerRole IMRI | Organization Hospital Department IMRI)	誰證明了此Composition
custodian		0..1	Reference(Organization Hospital Department IMRI)	維護Composition的機構
Slices for section		1..*	BackboneElement	Composition被分成一個或數個小節 Slice: Unordered, Closed by value:code
section:PatientInformation	S	0..1	BackboneElement	Composition被分成一個或數個小節
title		0..1	string	小節標籤(例如：目錄ToC) Fixed Value: 病人資訊
code		1..1	CodeableConceptTW	小節分類(建議) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 52460-3
display		1..1	string	Representation defined by the system Fixed Value: Patient Information
Slices for section		0..1		嵌套的小節 Slice: Unordered, Closed by profile:entry.resolve()
section:bloodtype		0..1	BackboneElement	嵌套的小節
code		0..1	CodeableConcept	Classification of section (recommended) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 882-1
display		1..1	string	Representation defined by the system Fixed Value: ABO and Rh group [Type] in Blood
entry		0..*	Reference(ObservationBloodType IMRI)	A reference to data that supports this section
section:OperationNote	S	1..*	BackboneElement	Composition被分成一個或數個小節
title		0..1	string	小節標籤(例如：目錄ToC) Fixed Value: 手術資訊
code		1..1	CodeableConceptTW	小節分類(建議) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11504-8
display		1..1	string	Representation defined by the system Fixed Value: Surgical operation note
entry		1..*	Reference(ProcedureOperation IMRI)	提供一個連結用於參照或查看支持此小節內容的資料
Slices for section	C	0..3		嵌套的小節 Slice: Unordered, Closed by profile:entry.resolve() imri-1: Composition.section.section.text or Composition.section.section.entry SHALL be present
Slices for section				Content/Rules for all slices
section:postoperativeDiagnosis	C	0..1	BackboneElement	嵌套的小節
code		1..1	CodeableConcept	Classification of section (recommended) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 10218-6
display		1..1	string	Representation defined by the system Fixed Value: Surgical operation note postoperative diagnosis Narrative
entry		0..*	Reference(TW Core Condition)	A reference to data that supports this section
Slices for section				Content/Rules for all slices
section:bloodLoss	C	0..1	BackboneElement	嵌套的小節
code		1..1	CodeableConcept	Classification of section (recommended) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 59770-8
display		1..1	string	Representation defined by the system Fixed Value: Procedure estimated blood loss Narrative
entry		0..*	Reference(ObservationBloodLoss IMRI)	A reference to data that supports this section
Slices for section				Content/Rules for all slices
section:anesthesiaMode	C	0..1	BackboneElement	嵌套的小節
code		1..1	CodeableConcept	Classification of section (recommended) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 59774-0
display		1..1	string	Representation defined by the system Fixed Value: Procedure anesthesia Narrative
entry		0..*	Reference(ProcedureAnesthesiaMode IMRI)	A reference to data that supports this section
Documentation for this format

Constraints

Id	Grade	Path(s)	Details	Requirements
imri-1	error	Composition.section:OperationNote.section	Composition.section.section.text or Composition.section.section.entry SHALL be present : text.exists() or entry.exists()

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	TWCoreComposition	將一組resources組成一份連貫的臨床聲明，並附有臨床證明。
implicitRules	?!Σ	0..1	uri	創建此內容所依據的一組規則
modifierExtension	?!	0..*	Extension	此擴充的資料項目可能會完全修正或改變其他資料項目的意涵，需特別留意。
identifier	SΣ	0..1	Identifier	不分版本的臨床文件架構(Composition)識別碼。
status	?!SΣ	1..1	code	registered | partial | preliminary | final | amended | corrected + Binding: CompositionStatus (required): Composition的工作流程/臨床狀態；應填入所綁定值集中的其中一個代碼。 Required Pattern: final
type	S	1..1	CodeableConceptTW	Composition的種類（如果可能請使用LOINC） Binding: FHIRDocumentTypeCodes (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。 Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11504-8
display		1..1	string	Representation defined by the system Fixed Value: Surgical operation note
subject	SΣ	1..1	Reference(Patient IMRI)	Composition是關於誰和/或什麼
encounter	Σ	0..1	Reference(Encounter IMRI)	Composition的情境
date	SΣ	1..1	dateTime	Composition的編輯時間
author	SΣ	1..*	Reference(Organization Hospital Department IMRI | Practitioner IMRI)	誰和/或什麼創建了這個Composition
title	SΣ	1..1	string	人類可讀的名稱/標題 Fixed Value: 手術紀錄
attester	S	0..*	BackboneElement	證明Composition的準確性
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode		1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): 認證者提供的認證類型；應填入所綁定值集中的其中一個代碼。
party		0..1	Reference(Patient IMRI | RelatedPerson | Practitioner IMRI | PractitionerRole IMRI | Organization Hospital Department IMRI)	誰證明了此Composition
custodian	SΣ	0..1	Reference(Organization Hospital Department IMRI)	維護Composition的機構
Slices for section	SC	1..*	BackboneElement	Composition被分成一個或數個小節 Slice: Unordered, Closed by value:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
section:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	0..1	CodeableConceptTW	小節分類(建議) Binding: DocumentSectionCodes (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。
text	SC	0..1	Narrative	將文件中特定小節的內容簡化成容易理解的文字形式，便於人類閱讀和解釋。
entry	SC	0..*	Reference(Resource)	提供一個連結用於參照或查看支持此小節內容的資料
section:PatientInformation	SC	0..1	BackboneElement	Composition被分成一個或數個小節 cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	小節標籤(例如：目錄ToC) Fixed Value: 病人資訊
code	S	1..1	CodeableConceptTW	小節分類(建議) Binding: DocumentSectionCodes (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。 Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 52460-3
display		1..1	string	Representation defined by the system Fixed Value: Patient Information
text	SC	0..1	Narrative	將文件中特定小節的內容簡化成容易理解的文字形式，便於人類閱讀和解釋。
entry	SC	0..*	Reference(Resource)	提供一個連結用於參照或查看支持此小節內容的資料
Slices for section	C	0..1	See section (Composition)	嵌套的小節 Slice: Unordered, Closed by profile:entry.resolve()
section:bloodtype	C	0..1	BackboneElement	嵌套的小節
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 882-1
display		1..1	string	Representation defined by the system Fixed Value: ABO and Rh group [Type] in Blood
entry	C	0..*	Reference(ObservationBloodType IMRI)	A reference to data that supports this section
section:OperationNote	SC	1..*	BackboneElement	Composition被分成一個或數個小節 cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	小節標籤(例如：目錄ToC) Fixed Value: 手術資訊
code	S	1..1	CodeableConceptTW	小節分類(建議) Binding: DocumentSectionCodes (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。 Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11504-8
display		1..1	string	Representation defined by the system Fixed Value: Surgical operation note
text	SC	0..1	Narrative	將文件中特定小節的內容簡化成容易理解的文字形式，便於人類閱讀和解釋。
entry	SC	1..*	Reference(ProcedureOperation IMRI)	提供一個連結用於參照或查看支持此小節內容的資料
Slices for section	C	0..3	See section (Composition)	嵌套的小節 Slice: Unordered, Closed by profile:entry.resolve() imri-1: Composition.section.section.text or Composition.section.section.entry SHALL be present
Slices for section				Content/Rules for all slices
section:postoperativeDiagnosis	C	0..1	BackboneElement	嵌套的小節
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 10218-6
display		1..1	string	Representation defined by the system Fixed Value: Surgical operation note postoperative diagnosis Narrative
entry	C	0..*	Reference(TW Core Condition)	A reference to data that supports this section
Slices for section				Content/Rules for all slices
section:bloodLoss	C	0..1	BackboneElement	嵌套的小節
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 59770-8
display		1..1	string	Representation defined by the system Fixed Value: Procedure estimated blood loss Narrative
entry	C	0..*	Reference(ObservationBloodLoss IMRI)	A reference to data that supports this section
Slices for section				Content/Rules for all slices
section:anesthesiaMode	C	0..1	BackboneElement	嵌套的小節
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 59774-0
display		1..1	string	Representation defined by the system Fixed Value: Procedure anesthesia Narrative
entry	C	0..*	Reference(ProcedureAnesthesiaMode IMRI)	A reference to data that supports this section
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.status	required	Pattern: final http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	extensible	Pattern: LOINC Code 11504-8("Surgical operation note") http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.section.code	extensible	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:PatientInformation.code	extensible	Pattern: LOINC Code 52460-3("Patient Information") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:PatientInformation.section:bloodtype.code	example	Pattern: LOINC Code 882-1("ABO and Rh group [Type] in Blood") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:OperationNote.code	extensible	Pattern: LOINC Code 11504-8("Surgical operation note") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:OperationNote.section:postoperativeDiagnosis.code	example	Pattern: LOINC Code 10218-6("Surgical operation note postoperative diagnosis Narrative") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:OperationNote.section:bloodLoss.code	example	Pattern: LOINC Code 59770-8("Procedure estimated blood loss Narrative") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:OperationNote.section:anesthesiaMode.code	example	Pattern: LOINC Code 59774-0("Procedure anesthesia Narrative") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
imri-1	error	Composition.section:OperationNote.section	Composition.section.section.text or Composition.section.section.entry SHALL be present : text.exists() or entry.exists()

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	TWCoreComposition	將一組resources組成一份連貫的臨床聲明，並附有臨床證明。
id	Σ	0..1	id	不重複的ID用以識別儲存在特定FHIR Server中的Composition紀錄，通常又稱為邏輯性ID。
meta	Σ	0..1	Meta	此Composition 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Composition Resource內容的語言 Binding: CommonLanguages (preferred): 人類語言；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。 Additional Bindings Purpose AllLanguages Max Binding Example Value: zh-TW
text		0..1	Narrative	Composition Resource之內容摘要以供人閱讀
contained		0..*	Resource	內嵌的(contained)、行內的Resources
extension		0..*	Extension	擴充的資料項目
modifierExtension	?!	0..*	Extension	此擴充的資料項目可能會完全修正或改變其他資料項目的意涵，需特別留意。
identifier	SΣ	0..1	Identifier	不分版本的臨床文件架構(Composition)識別碼。
status	?!SΣ	1..1	code	registered | partial | preliminary | final | amended | corrected + Binding: CompositionStatus (required): Composition的工作流程/臨床狀態；應填入所綁定值集中的其中一個代碼。 Required Pattern: final
type	S	1..1	CodeableConceptTW	Composition的種類（如果可能請使用LOINC） Binding: FHIRDocumentTypeCodes (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。 Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11504-8
display		1..1	string	Representation defined by the system Fixed Value: Surgical operation note
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
category		0..*	CodeableConceptTW	Composition的分類 Binding: DocumentClassValueSet (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。
subject	SΣ	1..1	Reference(Patient IMRI)	Composition是關於誰和/或什麼
encounter	Σ	0..1	Reference(Encounter IMRI)	Composition的情境
date	SΣ	1..1	dateTime	Composition的編輯時間
author	SΣ	1..*	Reference(Organization Hospital Department IMRI | Practitioner IMRI)	誰和/或什麼創建了這個Composition
title	SΣ	1..1	string	人類可讀的名稱/標題 Fixed Value: 手術紀錄
confidentiality	Σ	0..1	code	根據特定技術領域的定義 Binding: v3.ConfidentialityClassification (2014-03-26) (required): 應填入所綁定值集中的其中一個代碼。
attester	S	0..*	BackboneElement	證明Composition的準確性
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
mode		1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): 認證者提供的認證類型；應填入所綁定值集中的其中一個代碼。
time		0..1	dateTime	此Composition被證明的時間
party		0..1	Reference(Patient IMRI | RelatedPerson | Practitioner IMRI | PractitionerRole IMRI | Organization Hospital Department IMRI)	誰證明了此Composition
custodian	SΣ	0..1	Reference(Organization Hospital Department IMRI)	維護Composition的機構
relatesTo		0..*	BackboneElement	與其他Composition/文件之間的關係
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
code		1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): 檔案之間的關係型別；應填入所綁定值集中的其中一個代碼。
target[x]		1..1		此關係的目標文件
targetIdentifier			Identifier
targetReference			Reference(Composition)
event	Σ	0..*	BackboneElement	正在記錄的臨床服務
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
code		0..*	CodeableConceptTW	此代碼表代表了正在被記錄的主要臨床行為 Binding: v3 Code System ActCode (example): 可參考所綁定值集，但此值集只是針對這個欄位的一個可能值的範例，不預期也不鼓勵使用者一定要使用此值集的代碼。
period	Σ	0..1	Period	文件所涵蓋的時間區間
detail	Σ	0..*	Reference(Resource)	在描述被記錄下來的事件，這些事件可以是以代碼的形式、參考資料的形式，或者兩者都有的形式來呈現。
Slices for section	SC	1..*	BackboneElement	Composition被分成一個或數個小節 Slice: Unordered, Closed by value:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
section:All Slices				Content/Rules for all slices
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
title		0..1	string	小節標籤(例如：目錄ToC)
code	S	0..1	CodeableConceptTW	小節分類(建議) Binding: DocumentSectionCodes (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。
author		0..*	Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | TW Core Patient | Device | RelatedPerson)	誰和/或什麼人撰寫了該小節
focus		0..1	Reference(Resource)	當小節與composition描述的對象無關時，此小節是關於誰/什麼。
text	SC	0..1	Narrative	將文件中特定小節的內容簡化成容易理解的文字形式，便於人類閱讀和解釋。
mode		0..1	code	適用於此小節的處理模式 Binding: ListMode (required): 應填入所綁定值集中的其中一個代碼。
orderedBy		0..1	CodeableConceptTW	小節條目的順序 Binding: ListOrderCodes (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。
entry	SC	0..*	Reference(Resource)	提供一個連結用於參照或查看支持此小節內容的資料
emptyReason		0..1	CodeableConceptTW	為什麼此小節是空的原因 Binding: ListEmptyReasons (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。
section	C	0..*	See section (Composition)	嵌套的小節
section:PatientInformation	SC	0..1	BackboneElement	Composition被分成一個或數個小節 cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
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
title		0..1	string	小節標籤(例如：目錄ToC) Fixed Value: 病人資訊
code	S	1..1	CodeableConceptTW	小節分類(建議) Binding: DocumentSectionCodes (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。 Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 52460-3
display		1..1	string	Representation defined by the system Fixed Value: Patient Information
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | TW Core Patient | Device | RelatedPerson)	誰和/或什麼人撰寫了該小節
focus		0..1	Reference(Resource)	當小節與composition描述的對象無關時，此小節是關於誰/什麼。
text	SC	0..1	Narrative	將文件中特定小節的內容簡化成容易理解的文字形式，便於人類閱讀和解釋。
mode		0..1	code	適用於此小節的處理模式 Binding: ListMode (required): 應填入所綁定值集中的其中一個代碼。
orderedBy		0..1	CodeableConceptTW	小節條目的順序 Binding: ListOrderCodes (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。
entry	SC	0..*	Reference(Resource)	提供一個連結用於參照或查看支持此小節內容的資料
emptyReason		0..1	CodeableConceptTW	為什麼此小節是空的原因 Binding: ListEmptyReasons (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。
Slices for section	C	0..1	See section (Composition)	嵌套的小節 Slice: Unordered, Closed by profile:entry.resolve()
Slices for section				Content/Rules for all slices
section:bloodtype	C	0..1	BackboneElement	嵌套的小節
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
title		0..1	string	Label for section (e.g. for ToC)
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 882-1
display		1..1	string	Representation defined by the system Fixed Value: ABO and Rh group [Type] in Blood
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(ObservationBloodType IMRI)	A reference to data that supports this section
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:OperationNote	SC	1..*	BackboneElement	Composition被分成一個或數個小節 cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
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
title		0..1	string	小節標籤(例如：目錄ToC) Fixed Value: 手術資訊
code	S	1..1	CodeableConceptTW	小節分類(建議) Binding: DocumentSectionCodes (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。 Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11504-8
display		1..1	string	Representation defined by the system Fixed Value: Surgical operation note
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | TW Core Patient | Device | RelatedPerson)	誰和/或什麼人撰寫了該小節
focus		0..1	Reference(Resource)	當小節與composition描述的對象無關時，此小節是關於誰/什麼。
text	SC	0..1	Narrative	將文件中特定小節的內容簡化成容易理解的文字形式，便於人類閱讀和解釋。
mode		0..1	code	適用於此小節的處理模式 Binding: ListMode (required): 應填入所綁定值集中的其中一個代碼。
orderedBy		0..1	CodeableConceptTW	小節條目的順序 Binding: ListOrderCodes (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。
entry	SC	1..*	Reference(ProcedureOperation IMRI)	提供一個連結用於參照或查看支持此小節內容的資料
emptyReason		0..1	CodeableConceptTW	為什麼此小節是空的原因 Binding: ListEmptyReasons (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。
Slices for section	C	0..3	See section (Composition)	嵌套的小節 Slice: Unordered, Closed by profile:entry.resolve() imri-1: Composition.section.section.text or Composition.section.section.entry SHALL be present
Slices for section				Content/Rules for all slices
section:postoperativeDiagnosis	C	0..1	BackboneElement	嵌套的小節
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
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 10218-6
display		1..1	string	Representation defined by the system Fixed Value: Surgical operation note postoperative diagnosis Narrative
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(TW Core Condition)	A reference to data that supports this section
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
Slices for section				Content/Rules for all slices
section:bloodLoss	C	0..1	BackboneElement	嵌套的小節
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
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 59770-8
display		1..1	string	Representation defined by the system Fixed Value: Procedure estimated blood loss Narrative
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(ObservationBloodLoss IMRI)	A reference to data that supports this section
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
Slices for section				Content/Rules for all slices
section:anesthesiaMode	C	0..1	BackboneElement	嵌套的小節
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
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 59774-0
display		1..1	string	Representation defined by the system Fixed Value: Procedure anesthesia Narrative
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(ProcedureAnesthesiaMode IMRI)	A reference to data that supports this section
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Composition.status	required	Pattern: final http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	extensible	Pattern: LOINC Code 11504-8("Surgical operation note") http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard
Composition.category	extensible	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
Composition.confidentiality	required	v3.ConfidentialityClassification http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 from the FHIR Standard
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
Composition.event.code	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.code	extensible	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:PatientInformation.code	extensible	Pattern: LOINC Code 52460-3("Patient Information") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:PatientInformation.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:PatientInformation.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:PatientInformation.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:PatientInformation.section:bloodtype.code	example	Pattern: LOINC Code 882-1("ABO and Rh group [Type] in Blood") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:PatientInformation.section:bloodtype.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:PatientInformation.section:bloodtype.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:PatientInformation.section:bloodtype.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:OperationNote.code	extensible	Pattern: LOINC Code 11504-8("Surgical operation note") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:OperationNote.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:OperationNote.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:OperationNote.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:OperationNote.section:postoperativeDiagnosis.code	example	Pattern: LOINC Code 10218-6("Surgical operation note postoperative diagnosis Narrative") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:OperationNote.section:postoperativeDiagnosis.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:OperationNote.section:postoperativeDiagnosis.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:OperationNote.section:postoperativeDiagnosis.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:OperationNote.section:bloodLoss.code	example	Pattern: LOINC Code 59770-8("Procedure estimated blood loss Narrative") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:OperationNote.section:bloodLoss.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:OperationNote.section:bloodLoss.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:OperationNote.section:bloodLoss.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:OperationNote.section:anesthesiaMode.code	example	Pattern: LOINC Code 59774-0("Procedure anesthesia Narrative") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:OperationNote.section:anesthesiaMode.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:OperationNote.section:anesthesiaMode.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:OperationNote.section:anesthesiaMode.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
imri-1	error	Composition.section:OperationNote.section	Composition.section.section.text or Composition.section.section.entry SHALL be present : text.exists() or entry.exists()

This structure is derived from TWCoreComposition

Summary

Mandatory: 5 elements(4 nested mandatory elements)
Must-Support: 2 elements
Fixed: 3 elements

Structures

This structure refers to these other structures:

• Patient IMRI (https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/patient-imri)
• Encounter IMRI (https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/encounter-imri)
• Organization Hospital Department IMRI (https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/organization-hosp-imri)
• Practitioner IMRI (https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/practitioner-imri)
• PractitionerRole IMRI (https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/practitionerrole-imri)
• ObservationBloodType IMRI (https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/observationbloodtype-imri)
• ProcedureOperation IMRI (https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/procedureoperation-imri)
• TW Core Condition (https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Condition-twcore)
• ObservationBloodLoss IMRI (https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/observationbloodloss-imri)
• ProcedureAnesthesiaMode IMRI (https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/procedure-anesthesiamode-imri)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Composition.section (Closed)
• The element 1 is sliced based on the value of Composition.section.section (Closed)

Differential View

This structure is derived from TWCoreComposition

Name	Flags	Card.	Type	Description & Constraints
Composition			TWCoreComposition
status		1..1	code	registered | partial | preliminary | final | amended | corrected + Required Pattern: final
type		1..1	CodeableConceptTW	Composition的種類（如果可能請使用LOINC） Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11504-8
display		1..1	string	Representation defined by the system Fixed Value: Surgical operation note
subject		1..1	Reference(Patient IMRI)	Composition是關於誰和/或什麼
encounter		0..1	Reference(Encounter IMRI)	Composition的情境
author		1..*	Reference(Organization Hospital Department IMRI | Practitioner IMRI)	誰和/或什麼創建了這個Composition
title		1..1	string	人類可讀的名稱/標題 Fixed Value: 手術紀錄
attester
party		0..1	Reference(Patient IMRI | RelatedPerson | Practitioner IMRI | PractitionerRole IMRI | Organization Hospital Department IMRI)	誰證明了此Composition
custodian		0..1	Reference(Organization Hospital Department IMRI)	維護Composition的機構
Slices for section		1..*	BackboneElement	Composition被分成一個或數個小節 Slice: Unordered, Closed by value:code
section:PatientInformation	S	0..1	BackboneElement	Composition被分成一個或數個小節
title		0..1	string	小節標籤(例如：目錄ToC) Fixed Value: 病人資訊
code		1..1	CodeableConceptTW	小節分類(建議) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 52460-3
display		1..1	string	Representation defined by the system Fixed Value: Patient Information
Slices for section		0..1		嵌套的小節 Slice: Unordered, Closed by profile:entry.resolve()
section:bloodtype		0..1	BackboneElement	嵌套的小節
code		0..1	CodeableConcept	Classification of section (recommended) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 882-1
display		1..1	string	Representation defined by the system Fixed Value: ABO and Rh group [Type] in Blood
entry		0..*	Reference(ObservationBloodType IMRI)	A reference to data that supports this section
section:OperationNote	S	1..*	BackboneElement	Composition被分成一個或數個小節
title		0..1	string	小節標籤(例如：目錄ToC) Fixed Value: 手術資訊
code		1..1	CodeableConceptTW	小節分類(建議) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11504-8
display		1..1	string	Representation defined by the system Fixed Value: Surgical operation note
entry		1..*	Reference(ProcedureOperation IMRI)	提供一個連結用於參照或查看支持此小節內容的資料
Slices for section	C	0..3		嵌套的小節 Slice: Unordered, Closed by profile:entry.resolve() imri-1: Composition.section.section.text or Composition.section.section.entry SHALL be present
Slices for section				Content/Rules for all slices
section:postoperativeDiagnosis	C	0..1	BackboneElement	嵌套的小節
code		1..1	CodeableConcept	Classification of section (recommended) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 10218-6
display		1..1	string	Representation defined by the system Fixed Value: Surgical operation note postoperative diagnosis Narrative
entry		0..*	Reference(TW Core Condition)	A reference to data that supports this section
Slices for section				Content/Rules for all slices
section:bloodLoss	C	0..1	BackboneElement	嵌套的小節
code		1..1	CodeableConcept	Classification of section (recommended) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 59770-8
display		1..1	string	Representation defined by the system Fixed Value: Procedure estimated blood loss Narrative
entry		0..*	Reference(ObservationBloodLoss IMRI)	A reference to data that supports this section
Slices for section				Content/Rules for all slices
section:anesthesiaMode	C	0..1	BackboneElement	嵌套的小節
code		1..1	CodeableConcept	Classification of section (recommended) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 59774-0
display		1..1	string	Representation defined by the system Fixed Value: Procedure anesthesia Narrative
entry		0..*	Reference(ProcedureAnesthesiaMode IMRI)	A reference to data that supports this section
Documentation for this format

Constraints

Id	Grade	Path(s)	Details	Requirements
imri-1	error	Composition.section:OperationNote.section	Composition.section.section.text or Composition.section.section.entry SHALL be present : text.exists() or entry.exists()

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	TWCoreComposition	將一組resources組成一份連貫的臨床聲明，並附有臨床證明。
implicitRules	?!Σ	0..1	uri	創建此內容所依據的一組規則
modifierExtension	?!	0..*	Extension	此擴充的資料項目可能會完全修正或改變其他資料項目的意涵，需特別留意。
identifier	SΣ	0..1	Identifier	不分版本的臨床文件架構(Composition)識別碼。
status	?!SΣ	1..1	code	registered | partial | preliminary | final | amended | corrected + Binding: CompositionStatus (required): Composition的工作流程/臨床狀態；應填入所綁定值集中的其中一個代碼。 Required Pattern: final
type	S	1..1	CodeableConceptTW	Composition的種類（如果可能請使用LOINC） Binding: FHIRDocumentTypeCodes (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。 Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11504-8
display		1..1	string	Representation defined by the system Fixed Value: Surgical operation note
subject	SΣ	1..1	Reference(Patient IMRI)	Composition是關於誰和/或什麼
encounter	Σ	0..1	Reference(Encounter IMRI)	Composition的情境
date	SΣ	1..1	dateTime	Composition的編輯時間
author	SΣ	1..*	Reference(Organization Hospital Department IMRI | Practitioner IMRI)	誰和/或什麼創建了這個Composition
title	SΣ	1..1	string	人類可讀的名稱/標題 Fixed Value: 手術紀錄
attester	S	0..*	BackboneElement	證明Composition的準確性
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode		1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): 認證者提供的認證類型；應填入所綁定值集中的其中一個代碼。
party		0..1	Reference(Patient IMRI | RelatedPerson | Practitioner IMRI | PractitionerRole IMRI | Organization Hospital Department IMRI)	誰證明了此Composition
custodian	SΣ	0..1	Reference(Organization Hospital Department IMRI)	維護Composition的機構
Slices for section	SC	1..*	BackboneElement	Composition被分成一個或數個小節 Slice: Unordered, Closed by value:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
section:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	0..1	CodeableConceptTW	小節分類(建議) Binding: DocumentSectionCodes (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。
text	SC	0..1	Narrative	將文件中特定小節的內容簡化成容易理解的文字形式，便於人類閱讀和解釋。
entry	SC	0..*	Reference(Resource)	提供一個連結用於參照或查看支持此小節內容的資料
section:PatientInformation	SC	0..1	BackboneElement	Composition被分成一個或數個小節 cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	小節標籤(例如：目錄ToC) Fixed Value: 病人資訊
code	S	1..1	CodeableConceptTW	小節分類(建議) Binding: DocumentSectionCodes (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。 Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 52460-3
display		1..1	string	Representation defined by the system Fixed Value: Patient Information
text	SC	0..1	Narrative	將文件中特定小節的內容簡化成容易理解的文字形式，便於人類閱讀和解釋。
entry	SC	0..*	Reference(Resource)	提供一個連結用於參照或查看支持此小節內容的資料
Slices for section	C	0..1	See section (Composition)	嵌套的小節 Slice: Unordered, Closed by profile:entry.resolve()
section:bloodtype	C	0..1	BackboneElement	嵌套的小節
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 882-1
display		1..1	string	Representation defined by the system Fixed Value: ABO and Rh group [Type] in Blood
entry	C	0..*	Reference(ObservationBloodType IMRI)	A reference to data that supports this section
section:OperationNote	SC	1..*	BackboneElement	Composition被分成一個或數個小節 cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	小節標籤(例如：目錄ToC) Fixed Value: 手術資訊
code	S	1..1	CodeableConceptTW	小節分類(建議) Binding: DocumentSectionCodes (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。 Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11504-8
display		1..1	string	Representation defined by the system Fixed Value: Surgical operation note
text	SC	0..1	Narrative	將文件中特定小節的內容簡化成容易理解的文字形式，便於人類閱讀和解釋。
entry	SC	1..*	Reference(ProcedureOperation IMRI)	提供一個連結用於參照或查看支持此小節內容的資料
Slices for section	C	0..3	See section (Composition)	嵌套的小節 Slice: Unordered, Closed by profile:entry.resolve() imri-1: Composition.section.section.text or Composition.section.section.entry SHALL be present
Slices for section				Content/Rules for all slices
section:postoperativeDiagnosis	C	0..1	BackboneElement	嵌套的小節
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 10218-6
display		1..1	string	Representation defined by the system Fixed Value: Surgical operation note postoperative diagnosis Narrative
entry	C	0..*	Reference(TW Core Condition)	A reference to data that supports this section
Slices for section				Content/Rules for all slices
section:bloodLoss	C	0..1	BackboneElement	嵌套的小節
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 59770-8
display		1..1	string	Representation defined by the system Fixed Value: Procedure estimated blood loss Narrative
entry	C	0..*	Reference(ObservationBloodLoss IMRI)	A reference to data that supports this section
Slices for section				Content/Rules for all slices
section:anesthesiaMode	C	0..1	BackboneElement	嵌套的小節
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 59774-0
display		1..1	string	Representation defined by the system Fixed Value: Procedure anesthesia Narrative
entry	C	0..*	Reference(ProcedureAnesthesiaMode IMRI)	A reference to data that supports this section
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.status	required	Pattern: final http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	extensible	Pattern: LOINC Code 11504-8("Surgical operation note") http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.section.code	extensible	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:PatientInformation.code	extensible	Pattern: LOINC Code 52460-3("Patient Information") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:PatientInformation.section:bloodtype.code	example	Pattern: LOINC Code 882-1("ABO and Rh group [Type] in Blood") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:OperationNote.code	extensible	Pattern: LOINC Code 11504-8("Surgical operation note") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:OperationNote.section:postoperativeDiagnosis.code	example	Pattern: LOINC Code 10218-6("Surgical operation note postoperative diagnosis Narrative") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:OperationNote.section:bloodLoss.code	example	Pattern: LOINC Code 59770-8("Procedure estimated blood loss Narrative") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:OperationNote.section:anesthesiaMode.code	example	Pattern: LOINC Code 59774-0("Procedure anesthesia Narrative") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
imri-1	error	Composition.section:OperationNote.section	Composition.section.section.text or Composition.section.section.entry SHALL be present : text.exists() or entry.exists()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	TWCoreComposition	將一組resources組成一份連貫的臨床聲明，並附有臨床證明。
id	Σ	0..1	id	不重複的ID用以識別儲存在特定FHIR Server中的Composition紀錄，通常又稱為邏輯性ID。
meta	Σ	0..1	Meta	此Composition 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Composition Resource內容的語言 Binding: CommonLanguages (preferred): 人類語言；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。 Additional Bindings Purpose AllLanguages Max Binding Example Value: zh-TW
text		0..1	Narrative	Composition Resource之內容摘要以供人閱讀
contained		0..*	Resource	內嵌的(contained)、行內的Resources
extension		0..*	Extension	擴充的資料項目
modifierExtension	?!	0..*	Extension	此擴充的資料項目可能會完全修正或改變其他資料項目的意涵，需特別留意。
identifier	SΣ	0..1	Identifier	不分版本的臨床文件架構(Composition)識別碼。
status	?!SΣ	1..1	code	registered | partial | preliminary | final | amended | corrected + Binding: CompositionStatus (required): Composition的工作流程/臨床狀態；應填入所綁定值集中的其中一個代碼。 Required Pattern: final
type	S	1..1	CodeableConceptTW	Composition的種類（如果可能請使用LOINC） Binding: FHIRDocumentTypeCodes (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。 Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11504-8
display		1..1	string	Representation defined by the system Fixed Value: Surgical operation note
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
category		0..*	CodeableConceptTW	Composition的分類 Binding: DocumentClassValueSet (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。
subject	SΣ	1..1	Reference(Patient IMRI)	Composition是關於誰和/或什麼
encounter	Σ	0..1	Reference(Encounter IMRI)	Composition的情境
date	SΣ	1..1	dateTime	Composition的編輯時間
author	SΣ	1..*	Reference(Organization Hospital Department IMRI | Practitioner IMRI)	誰和/或什麼創建了這個Composition
title	SΣ	1..1	string	人類可讀的名稱/標題 Fixed Value: 手術紀錄
confidentiality	Σ	0..1	code	根據特定技術領域的定義 Binding: v3.ConfidentialityClassification (2014-03-26) (required): 應填入所綁定值集中的其中一個代碼。
attester	S	0..*	BackboneElement	證明Composition的準確性
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
mode		1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): 認證者提供的認證類型；應填入所綁定值集中的其中一個代碼。
time		0..1	dateTime	此Composition被證明的時間
party		0..1	Reference(Patient IMRI | RelatedPerson | Practitioner IMRI | PractitionerRole IMRI | Organization Hospital Department IMRI)	誰證明了此Composition
custodian	SΣ	0..1	Reference(Organization Hospital Department IMRI)	維護Composition的機構
relatesTo		0..*	BackboneElement	與其他Composition/文件之間的關係
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
code		1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): 檔案之間的關係型別；應填入所綁定值集中的其中一個代碼。
target[x]		1..1		此關係的目標文件
targetIdentifier			Identifier
targetReference			Reference(Composition)
event	Σ	0..*	BackboneElement	正在記錄的臨床服務
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
code		0..*	CodeableConceptTW	此代碼表代表了正在被記錄的主要臨床行為 Binding: v3 Code System ActCode (example): 可參考所綁定值集，但此值集只是針對這個欄位的一個可能值的範例，不預期也不鼓勵使用者一定要使用此值集的代碼。
period	Σ	0..1	Period	文件所涵蓋的時間區間
detail	Σ	0..*	Reference(Resource)	在描述被記錄下來的事件，這些事件可以是以代碼的形式、參考資料的形式，或者兩者都有的形式來呈現。
Slices for section	SC	1..*	BackboneElement	Composition被分成一個或數個小節 Slice: Unordered, Closed by value:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
section:All Slices				Content/Rules for all slices
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
title		0..1	string	小節標籤(例如：目錄ToC)
code	S	0..1	CodeableConceptTW	小節分類(建議) Binding: DocumentSectionCodes (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。
author		0..*	Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | TW Core Patient | Device | RelatedPerson)	誰和/或什麼人撰寫了該小節
focus		0..1	Reference(Resource)	當小節與composition描述的對象無關時，此小節是關於誰/什麼。
text	SC	0..1	Narrative	將文件中特定小節的內容簡化成容易理解的文字形式，便於人類閱讀和解釋。
mode		0..1	code	適用於此小節的處理模式 Binding: ListMode (required): 應填入所綁定值集中的其中一個代碼。
orderedBy		0..1	CodeableConceptTW	小節條目的順序 Binding: ListOrderCodes (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。
entry	SC	0..*	Reference(Resource)	提供一個連結用於參照或查看支持此小節內容的資料
emptyReason		0..1	CodeableConceptTW	為什麼此小節是空的原因 Binding: ListEmptyReasons (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。
section	C	0..*	See section (Composition)	嵌套的小節
section:PatientInformation	SC	0..1	BackboneElement	Composition被分成一個或數個小節 cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
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
title		0..1	string	小節標籤(例如：目錄ToC) Fixed Value: 病人資訊
code	S	1..1	CodeableConceptTW	小節分類(建議) Binding: DocumentSectionCodes (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。 Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 52460-3
display		1..1	string	Representation defined by the system Fixed Value: Patient Information
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | TW Core Patient | Device | RelatedPerson)	誰和/或什麼人撰寫了該小節
focus		0..1	Reference(Resource)	當小節與composition描述的對象無關時，此小節是關於誰/什麼。
text	SC	0..1	Narrative	將文件中特定小節的內容簡化成容易理解的文字形式，便於人類閱讀和解釋。
mode		0..1	code	適用於此小節的處理模式 Binding: ListMode (required): 應填入所綁定值集中的其中一個代碼。
orderedBy		0..1	CodeableConceptTW	小節條目的順序 Binding: ListOrderCodes (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。
entry	SC	0..*	Reference(Resource)	提供一個連結用於參照或查看支持此小節內容的資料
emptyReason		0..1	CodeableConceptTW	為什麼此小節是空的原因 Binding: ListEmptyReasons (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。
Slices for section	C	0..1	See section (Composition)	嵌套的小節 Slice: Unordered, Closed by profile:entry.resolve()
Slices for section				Content/Rules for all slices
section:bloodtype	C	0..1	BackboneElement	嵌套的小節
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
title		0..1	string	Label for section (e.g. for ToC)
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 882-1
display		1..1	string	Representation defined by the system Fixed Value: ABO and Rh group [Type] in Blood
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(ObservationBloodType IMRI)	A reference to data that supports this section
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:OperationNote	SC	1..*	BackboneElement	Composition被分成一個或數個小節 cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
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
title		0..1	string	小節標籤(例如：目錄ToC) Fixed Value: 手術資訊
code	S	1..1	CodeableConceptTW	小節分類(建議) Binding: DocumentSectionCodes (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。 Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11504-8
display		1..1	string	Representation defined by the system Fixed Value: Surgical operation note
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | TW Core Patient | Device | RelatedPerson)	誰和/或什麼人撰寫了該小節
focus		0..1	Reference(Resource)	當小節與composition描述的對象無關時，此小節是關於誰/什麼。
text	SC	0..1	Narrative	將文件中特定小節的內容簡化成容易理解的文字形式，便於人類閱讀和解釋。
mode		0..1	code	適用於此小節的處理模式 Binding: ListMode (required): 應填入所綁定值集中的其中一個代碼。
orderedBy		0..1	CodeableConceptTW	小節條目的順序 Binding: ListOrderCodes (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。
entry	SC	1..*	Reference(ProcedureOperation IMRI)	提供一個連結用於參照或查看支持此小節內容的資料
emptyReason		0..1	CodeableConceptTW	為什麼此小節是空的原因 Binding: ListEmptyReasons (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。
Slices for section	C	0..3	See section (Composition)	嵌套的小節 Slice: Unordered, Closed by profile:entry.resolve() imri-1: Composition.section.section.text or Composition.section.section.entry SHALL be present
Slices for section				Content/Rules for all slices
section:postoperativeDiagnosis	C	0..1	BackboneElement	嵌套的小節
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
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 10218-6
display		1..1	string	Representation defined by the system Fixed Value: Surgical operation note postoperative diagnosis Narrative
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(TW Core Condition)	A reference to data that supports this section
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
Slices for section				Content/Rules for all slices
section:bloodLoss	C	0..1	BackboneElement	嵌套的小節
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
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 59770-8
display		1..1	string	Representation defined by the system Fixed Value: Procedure estimated blood loss Narrative
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(ObservationBloodLoss IMRI)	A reference to data that supports this section
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
Slices for section				Content/Rules for all slices
section:anesthesiaMode	C	0..1	BackboneElement	嵌套的小節
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
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 59774-0
display		1..1	string	Representation defined by the system Fixed Value: Procedure anesthesia Narrative
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(ProcedureAnesthesiaMode IMRI)	A reference to data that supports this section
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Composition.status	required	Pattern: final http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	extensible	Pattern: LOINC Code 11504-8("Surgical operation note") http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard
Composition.category	extensible	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
Composition.confidentiality	required	v3.ConfidentialityClassification http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 from the FHIR Standard
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
Composition.event.code	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.code	extensible	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:PatientInformation.code	extensible	Pattern: LOINC Code 52460-3("Patient Information") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:PatientInformation.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:PatientInformation.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:PatientInformation.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:PatientInformation.section:bloodtype.code	example	Pattern: LOINC Code 882-1("ABO and Rh group [Type] in Blood") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:PatientInformation.section:bloodtype.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:PatientInformation.section:bloodtype.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:PatientInformation.section:bloodtype.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:OperationNote.code	extensible	Pattern: LOINC Code 11504-8("Surgical operation note") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:OperationNote.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:OperationNote.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:OperationNote.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:OperationNote.section:postoperativeDiagnosis.code	example	Pattern: LOINC Code 10218-6("Surgical operation note postoperative diagnosis Narrative") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:OperationNote.section:postoperativeDiagnosis.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:OperationNote.section:postoperativeDiagnosis.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:OperationNote.section:postoperativeDiagnosis.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:OperationNote.section:bloodLoss.code	example	Pattern: LOINC Code 59770-8("Procedure estimated blood loss Narrative") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:OperationNote.section:bloodLoss.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:OperationNote.section:bloodLoss.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:OperationNote.section:bloodLoss.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard
Composition.section:OperationNote.section:anesthesiaMode.code	example	Pattern: LOINC Code 59774-0("Procedure anesthesia Narrative") http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section:OperationNote.section:anesthesiaMode.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section:OperationNote.section:anesthesiaMode.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section:OperationNote.section:anesthesiaMode.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
imri-1	error	Composition.section:OperationNote.section	Composition.section.section.text or Composition.section.section.entry SHALL be present : text.exists() or entry.exists()

This structure is derived from TWCoreComposition

Summary

Mandatory: 5 elements(4 nested mandatory elements)
Must-Support: 2 elements
Fixed: 3 elements

Structures

This structure refers to these other structures:

• Patient IMRI (https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/patient-imri)
• Encounter IMRI (https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/encounter-imri)
• Organization Hospital Department IMRI (https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/organization-hosp-imri)
• Practitioner IMRI (https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/practitioner-imri)
• PractitionerRole IMRI (https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/practitionerrole-imri)
• ObservationBloodType IMRI (https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/observationbloodtype-imri)
• ProcedureOperation IMRI (https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/procedureoperation-imri)
• TW Core Condition (https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Condition-twcore)
• ObservationBloodLoss IMRI (https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/observationbloodloss-imri)
• ProcedureAnesthesiaMode IMRI (https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/procedure-anesthesiamode-imri)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Composition.section (Closed)
• The element 1 is sliced based on the value of Composition.section.section (Closed)