醫查實作指引
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Resource Profile: ProcedureAnesthesiaMode IMRI

Official URL: https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/procedure-anesthesiamode-imri Version: 0.1.0
Active as of 2024-08-12 Computable Name: ProcedureAnesthesiaModeIMRI

此麻醉模式(ProcedureAnesthesiaMode IMRI)Profile說明本IG如何進一步定義臺灣核心-處置或手術(TW Core Procedure) Profile以呈現麻醉模式。

Usage:

Formal Views of Profile Content

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

This structure is derived from TWCoreProcedure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure TWCoreProcedure
... basedOn 0..* Reference(CarePlan IMRI | ServiceRequest) 此Procedure是基於什麼而履行
... partOf 0..* Reference(ProcedureOperation IMRI) 參照事件的一部分
... status 1..1 code preparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknown
Required Pattern: completed
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 399097000
... code 1..1 CodeableConceptTW 即為「麻醉模式」。
Binding: SNOMED CT Anesthesia值集 (required)
.... Slices for coding Content/Rules for all slices
..... coding:icd10-pcs-2021 0..0
..... coding:icd10-pcs-2014 0..0
..... coding:medical-service-payment 0..0
..... coding:sct-procedures 0..0
..... coding:SCTAnesthesia S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。
Binding: SNOMED CT Anesthesia值集 (required)
... subject 1..1 Reference(Patient IMRI) 處置/手術服務的對象
... encounter 0..1 Reference(Encounter IMRI) 就醫(Encounter)紀錄作為處置/手術的一部分
... recorder 0..1 Reference(Patient IMRI | Practitioner IMRI | PractitionerRole IMRI | RelatedPerson) 誰記錄此處置/手術
... asserter 0..1 Reference(Patient IMRI | Practitioner IMRI | PractitionerRole IMRI | RelatedPerson) 聲稱有此處置/手術的人
... performer 0..* BackboneElement 即為「麻醉醫師」,執行麻醉的人員
.... actor 1..1 Reference(PractitionerRole IMRI) 參照至健康照護服務提供者
.... onBehalfOf 0..1 Reference(Organization Hospital Department IMRI) 此裝置(Device)或健康照護服務提供者所屬機構(Organization)
... location 0..1 Reference(Location IMRI) 處置/手術發生的地點(Location)?
... reasonReference 0..* Reference(ConditionChiefComplaint IMRI | ObservationLaboratory IMRI | DiagnosticReport | DocumentReference) 執行此處置/手術的原因
... report 0..* Reference(DiagnosticReport | DocumentReference | CompositionOperationNote IMRI) 此處置/手術產生的任何報告
... complicationDetail 0..* Reference(ConditionComorbiditiesandComplications IMRI) 處置/手術後發生的病情、問題或診斷

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Procedure.coderequiredSCTAnesthesia
https://hitstdio.ntunhs.edu.tw/imri/ValueSet/anesthesia-sct
from this IG
Procedure.code.coding:SCTAnesthesiarequiredSCTAnesthesia
https://hitstdio.ntunhs.edu.tw/imri/ValueSet/anesthesia-sct
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..* TWCoreProcedure 正在或曾經對病人執行的動作
... 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。
... basedOn Σ 0..* Reference(CarePlan IMRI | ServiceRequest) 此Procedure是基於什麼而履行
... status ?!SΣ 1..1 code preparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): 應填入所綁定值集中的其中一個代碼


Required Pattern: completed
... category 1..1 CodeableConceptTW 處置/手術的分類。
Binding: ProcedureCategoryCodes(SNOMEDCT) (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


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://snomed.info/sct
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 399097000
... code S 1..1 CodeableConceptTW 即為「麻醉模式」。
Binding: SNOMED CT Anesthesia值集 (required)
.... Slices for coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。
Slice: Unordered, Open by pattern:$this
..... coding:loinc-procedures S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: LOINC處置或手術值集 (required)
..... coding:SCTAnesthesia S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。
Binding: SNOMED CT Anesthesia值集 (required)
.... text SΣ 0..1 string 概念的文字表示法
... subject SΣ 1..1 Reference(Patient IMRI) 處置/手術服務的對象
... encounter Σ 0..1 Reference(Encounter IMRI) 就醫(Encounter)紀錄作為處置/手術的一部分
... performed[x] SΣ 0..1 此處置/手術何時執行的?
.... performedDateTime dateTime
... recorder Σ 0..1 Reference(Patient IMRI | Practitioner IMRI | PractitionerRole IMRI | RelatedPerson) 誰記錄此處置/手術
... asserter SΣ 0..1 Reference(Patient IMRI | Practitioner IMRI | PractitionerRole IMRI | RelatedPerson) 聲稱有此處置/手術的人
... performer SΣ 0..* BackboneElement 即為「麻醉醫師」,執行麻醉的人員
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... actor SΣ 1..1 Reference(PractitionerRole IMRI) 參照至健康照護服務提供者
.... onBehalfOf S 0..1 Reference(Organization Hospital Department IMRI) 此裝置(Device)或健康照護服務提供者所屬機構(Organization)
... location Σ 0..1 Reference(Location IMRI) 處置/手術發生的地點(Location)?
... reasonReference Σ 0..* Reference(ConditionChiefComplaint IMRI | ObservationLaboratory IMRI | DiagnosticReport | DocumentReference) 執行此處置/手術的原因
... bodySite S 0..* CodeableConceptTW 目標身體部位。
Binding: SNOMEDCTBodyStructures (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... report 0..* Reference(DiagnosticReport | DocumentReference | CompositionOperationNote IMRI) 此處置/手術產生的任何報告
... complicationDetail 0..* Reference(ConditionComorbiditiesandComplications IMRI) 處置/手術後發生的病情、問題或診斷

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.statusrequiredPattern: completed
http://hl7.org/fhir/ValueSet/event-status|4.0.1
from the FHIR Standard
Procedure.categoryextensiblePattern: SNOMED-CT Code 399097000
http://hl7.org/fhir/ValueSet/procedure-category
from the FHIR Standard
Procedure.coderequiredSCTAnesthesia
https://hitstdio.ntunhs.edu.tw/imri/ValueSet/anesthesia-sct
from this IG
Procedure.code.coding:loinc-proceduresrequiredLOINCProcedureCodes (a valid code from LOINC)
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-procedure-code
Procedure.code.coding:SCTAnesthesiarequiredSCTAnesthesia
https://hitstdio.ntunhs.edu.tw/imri/ValueSet/anesthesia-sct
from this IG
Procedure.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..* TWCoreProcedure 正在或曾經對病人執行的動作
... id Σ 0..1 id 不重複的ID用以識別儲存在特定FHIR Server中的Procedure紀錄,通常又稱為邏輯性ID。
... meta Σ 0..1 Meta 此Procedure Resource的metadata
... implicitRules ?!Σ 0..1 uri 創建此內容所依據的一組規則
... language 0..1 code 用以表述Procedure Resource內容的語言。
Binding: CommonLanguages (preferred): 人類語言;鼓勵使用CommonLanguages代碼表中的代碼,但不強制一定要使用此代碼表,你也可使用其他代碼表的代碼或單純以文字表示。

Additional BindingsPurpose
AllLanguages Max Binding

Example Value: zh-TW
... text 0..1 Narrative Procedure Resource之內容摘要以供人閱讀
... contained 0..* Resource 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 Σ 0..* Identifier 此處置/手術的外部識別碼
... instantiatesCanonical Σ 0..* canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) 實例化FHIR計畫書(protocol)或定義
... instantiatesUri Σ 0..* uri 實例化外部計畫書(protocol)或定義
... basedOn Σ 0..* Reference(CarePlan IMRI | ServiceRequest) 此Procedure是基於什麼而履行
... partOf Σ 0..* Reference(ProcedureOperation IMRI) 參照事件的一部分
... status ?!SΣ 1..1 code preparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): 應填入所綁定值集中的其中一個代碼


Required Pattern: completed
... statusReason 0..1 CodeableConceptTW 當前狀態的原因。
Binding: ProcedureNotPerformedReason(SNOMED-CT) (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

... category 1..1 CodeableConceptTW 處置/手術的分類。
Binding: ProcedureCategoryCodes(SNOMEDCT) (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


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://snomed.info/sct
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 399097000
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... code S 1..1 CodeableConceptTW 即為「麻醉模式」。
Binding: SNOMED CT Anesthesia值集 (required)
.... id 0..1 string 唯一可識別ID,以供資料項目間相互參照。
.... extension 0..* Extension 擴充的資料項目
Slice: Unordered, Open by value:url
.... Slices for coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。
Slice: Unordered, Open by pattern:$this
..... coding:loinc-procedures S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: LOINC處置或手術值集 (required)
..... coding:SCTAnesthesia S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。
Binding: SNOMED CT Anesthesia值集 (required)
.... text SΣ 0..1 string 概念的文字表示法
... subject SΣ 1..1 Reference(Patient IMRI) 處置/手術服務的對象
... encounter Σ 0..1 Reference(Encounter IMRI) 就醫(Encounter)紀錄作為處置/手術的一部分
... performed[x] SΣ 0..1 此處置/手術何時執行的?
.... performedDateTime dateTime S
.... performedPeriod Period
.... performedString string
.... performedAge Age
.... performedRange Range
... recorder Σ 0..1 Reference(Patient IMRI | Practitioner IMRI | PractitionerRole IMRI | RelatedPerson) 誰記錄此處置/手術
... asserter SΣ 0..1 Reference(Patient IMRI | Practitioner IMRI | PractitionerRole IMRI | RelatedPerson) 聲稱有此處置/手術的人
... performer SΣ 0..* BackboneElement 即為「麻醉醫師」,執行麻醉的人員
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... function 0..1 CodeableConceptTW 執行的型別
Binding: ProcedurePerformerRoleCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

.... actor SΣ 1..1 Reference(PractitionerRole IMRI) 參照至健康照護服務提供者
.... onBehalfOf S 0..1 Reference(Organization Hospital Department IMRI) 此裝置(Device)或健康照護服務提供者所屬機構(Organization)
... location Σ 0..1 Reference(Location IMRI) 處置/手術發生的地點(Location)?
... reasonCode 0..* CodeableConceptTW 處置/手術執行原因代碼
Binding: ProcedureReasonCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... reasonReference Σ 0..* Reference(ConditionChiefComplaint IMRI | ObservationLaboratory IMRI | DiagnosticReport | DocumentReference) 執行此處置/手術的原因
... bodySite S 0..* CodeableConceptTW 目標身體部位。
Binding: SNOMEDCTBodyStructures (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... outcome 0..1 CodeableConceptTW 處置/手術的結果。
Binding: ProcedureOutcomeCodes(SNOMEDCT) (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

... report 0..* Reference(DiagnosticReport | DocumentReference | CompositionOperationNote IMRI) 此處置/手術產生的任何報告
... complication 0..* CodeableConceptTW 處置/手術後的併發症
Binding: Condition/Problem/DiagnosisCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... complicationDetail 0..* Reference(ConditionComorbiditiesandComplications IMRI) 處置/手術後發生的病情、問題或診斷
... followUp 0..* CodeableConceptTW 追蹤說明。
Binding: ProcedureFollowUpCodes(SNOMEDCT) (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... note 0..* Annotation 關於此處置/手術的附加資訊
... focalDevice 0..* BackboneElement 處理、植入的或移除的裝置
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... action 0..1 CodeableConceptTW 改變裝置的種類
Binding: ProcedureDeviceActionCodes (preferred): 鼓勵使用所綁定值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。

.... manipulated 1..1 Reference(Device) 被改變的裝置
... usedReference 0..* Reference(Device | Medication | Substance) 處置/手術中使用的項目/物品
... usedCode 0..* CodeableConceptTW 處置/手術中使用的項目之代碼
Binding: FHIRDeviceTypes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。



doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Procedure.statusrequiredPattern: completed
http://hl7.org/fhir/ValueSet/event-status|4.0.1
from the FHIR Standard
Procedure.statusReasonextensibleProcedureNotPerformedReason(SNOMED-CT)
http://hl7.org/fhir/ValueSet/procedure-not-performed-reason
from the FHIR Standard
Procedure.categoryextensiblePattern: SNOMED-CT Code 399097000
http://hl7.org/fhir/ValueSet/procedure-category
from the FHIR Standard
Procedure.coderequiredSCTAnesthesia
https://hitstdio.ntunhs.edu.tw/imri/ValueSet/anesthesia-sct
from this IG
Procedure.code.coding:loinc-proceduresrequiredLOINCProcedureCodes (a valid code from LOINC)
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-procedure-code
Procedure.code.coding:SCTAnesthesiarequiredSCTAnesthesia
https://hitstdio.ntunhs.edu.tw/imri/ValueSet/anesthesia-sct
from this IG
Procedure.performer.functionextensibleProcedurePerformerRoleCodes
http://hl7.org/fhir/ValueSet/performer-role
from the FHIR Standard
Procedure.reasonCodeextensibleProcedureReasonCodes
http://hl7.org/fhir/ValueSet/procedure-reason
from the FHIR Standard
Procedure.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Procedure.outcomeextensibleProcedureOutcomeCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-outcome
from the FHIR Standard
Procedure.complicationextensibleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Procedure.followUpextensibleProcedureFollowUpCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-followup
from the FHIR Standard
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
http://hl7.org/fhir/ValueSet/device-action
from the FHIR Standard
Procedure.usedCodeextensibleFHIRDeviceTypes
http://hl7.org/fhir/ValueSet/device-kind
from the FHIR Standard

Differential View

This structure is derived from TWCoreProcedure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure TWCoreProcedure
... basedOn 0..* Reference(CarePlan IMRI | ServiceRequest) 此Procedure是基於什麼而履行
... partOf 0..* Reference(ProcedureOperation IMRI) 參照事件的一部分
... status 1..1 code preparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknown
Required Pattern: completed
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 399097000
... code 1..1 CodeableConceptTW 即為「麻醉模式」。
Binding: SNOMED CT Anesthesia值集 (required)
.... Slices for coding Content/Rules for all slices
..... coding:icd10-pcs-2021 0..0
..... coding:icd10-pcs-2014 0..0
..... coding:medical-service-payment 0..0
..... coding:sct-procedures 0..0
..... coding:SCTAnesthesia S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。
Binding: SNOMED CT Anesthesia值集 (required)
... subject 1..1 Reference(Patient IMRI) 處置/手術服務的對象
... encounter 0..1 Reference(Encounter IMRI) 就醫(Encounter)紀錄作為處置/手術的一部分
... recorder 0..1 Reference(Patient IMRI | Practitioner IMRI | PractitionerRole IMRI | RelatedPerson) 誰記錄此處置/手術
... asserter 0..1 Reference(Patient IMRI | Practitioner IMRI | PractitionerRole IMRI | RelatedPerson) 聲稱有此處置/手術的人
... performer 0..* BackboneElement 即為「麻醉醫師」,執行麻醉的人員
.... actor 1..1 Reference(PractitionerRole IMRI) 參照至健康照護服務提供者
.... onBehalfOf 0..1 Reference(Organization Hospital Department IMRI) 此裝置(Device)或健康照護服務提供者所屬機構(Organization)
... location 0..1 Reference(Location IMRI) 處置/手術發生的地點(Location)?
... reasonReference 0..* Reference(ConditionChiefComplaint IMRI | ObservationLaboratory IMRI | DiagnosticReport | DocumentReference) 執行此處置/手術的原因
... report 0..* Reference(DiagnosticReport | DocumentReference | CompositionOperationNote IMRI) 此處置/手術產生的任何報告
... complicationDetail 0..* Reference(ConditionComorbiditiesandComplications IMRI) 處置/手術後發生的病情、問題或診斷

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Procedure.coderequiredSCTAnesthesia
https://hitstdio.ntunhs.edu.tw/imri/ValueSet/anesthesia-sct
from this IG
Procedure.code.coding:SCTAnesthesiarequiredSCTAnesthesia
https://hitstdio.ntunhs.edu.tw/imri/ValueSet/anesthesia-sct
from this IG

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..* TWCoreProcedure 正在或曾經對病人執行的動作
... 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。
... basedOn Σ 0..* Reference(CarePlan IMRI | ServiceRequest) 此Procedure是基於什麼而履行
... status ?!SΣ 1..1 code preparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): 應填入所綁定值集中的其中一個代碼


Required Pattern: completed
... category 1..1 CodeableConceptTW 處置/手術的分類。
Binding: ProcedureCategoryCodes(SNOMEDCT) (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


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://snomed.info/sct
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 399097000
... code S 1..1 CodeableConceptTW 即為「麻醉模式」。
Binding: SNOMED CT Anesthesia值集 (required)
.... Slices for coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。
Slice: Unordered, Open by pattern:$this
..... coding:loinc-procedures S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: LOINC處置或手術值集 (required)
..... coding:SCTAnesthesia S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。
Binding: SNOMED CT Anesthesia值集 (required)
.... text SΣ 0..1 string 概念的文字表示法
... subject SΣ 1..1 Reference(Patient IMRI) 處置/手術服務的對象
... encounter Σ 0..1 Reference(Encounter IMRI) 就醫(Encounter)紀錄作為處置/手術的一部分
... performed[x] SΣ 0..1 此處置/手術何時執行的?
.... performedDateTime dateTime
... recorder Σ 0..1 Reference(Patient IMRI | Practitioner IMRI | PractitionerRole IMRI | RelatedPerson) 誰記錄此處置/手術
... asserter SΣ 0..1 Reference(Patient IMRI | Practitioner IMRI | PractitionerRole IMRI | RelatedPerson) 聲稱有此處置/手術的人
... performer SΣ 0..* BackboneElement 即為「麻醉醫師」,執行麻醉的人員
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... actor SΣ 1..1 Reference(PractitionerRole IMRI) 參照至健康照護服務提供者
.... onBehalfOf S 0..1 Reference(Organization Hospital Department IMRI) 此裝置(Device)或健康照護服務提供者所屬機構(Organization)
... location Σ 0..1 Reference(Location IMRI) 處置/手術發生的地點(Location)?
... reasonReference Σ 0..* Reference(ConditionChiefComplaint IMRI | ObservationLaboratory IMRI | DiagnosticReport | DocumentReference) 執行此處置/手術的原因
... bodySite S 0..* CodeableConceptTW 目標身體部位。
Binding: SNOMEDCTBodyStructures (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... report 0..* Reference(DiagnosticReport | DocumentReference | CompositionOperationNote IMRI) 此處置/手術產生的任何報告
... complicationDetail 0..* Reference(ConditionComorbiditiesandComplications IMRI) 處置/手術後發生的病情、問題或診斷

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.statusrequiredPattern: completed
http://hl7.org/fhir/ValueSet/event-status|4.0.1
from the FHIR Standard
Procedure.categoryextensiblePattern: SNOMED-CT Code 399097000
http://hl7.org/fhir/ValueSet/procedure-category
from the FHIR Standard
Procedure.coderequiredSCTAnesthesia
https://hitstdio.ntunhs.edu.tw/imri/ValueSet/anesthesia-sct
from this IG
Procedure.code.coding:loinc-proceduresrequiredLOINCProcedureCodes (a valid code from LOINC)
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-procedure-code
Procedure.code.coding:SCTAnesthesiarequiredSCTAnesthesia
https://hitstdio.ntunhs.edu.tw/imri/ValueSet/anesthesia-sct
from this IG
Procedure.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..* TWCoreProcedure 正在或曾經對病人執行的動作
... id Σ 0..1 id 不重複的ID用以識別儲存在特定FHIR Server中的Procedure紀錄,通常又稱為邏輯性ID。
... meta Σ 0..1 Meta 此Procedure Resource的metadata
... implicitRules ?!Σ 0..1 uri 創建此內容所依據的一組規則
... language 0..1 code 用以表述Procedure Resource內容的語言。
Binding: CommonLanguages (preferred): 人類語言;鼓勵使用CommonLanguages代碼表中的代碼,但不強制一定要使用此代碼表,你也可使用其他代碼表的代碼或單純以文字表示。

Additional BindingsPurpose
AllLanguages Max Binding

Example Value: zh-TW
... text 0..1 Narrative Procedure Resource之內容摘要以供人閱讀
... contained 0..* Resource 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 Σ 0..* Identifier 此處置/手術的外部識別碼
... instantiatesCanonical Σ 0..* canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) 實例化FHIR計畫書(protocol)或定義
... instantiatesUri Σ 0..* uri 實例化外部計畫書(protocol)或定義
... basedOn Σ 0..* Reference(CarePlan IMRI | ServiceRequest) 此Procedure是基於什麼而履行
... partOf Σ 0..* Reference(ProcedureOperation IMRI) 參照事件的一部分
... status ?!SΣ 1..1 code preparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): 應填入所綁定值集中的其中一個代碼


Required Pattern: completed
... statusReason 0..1 CodeableConceptTW 當前狀態的原因。
Binding: ProcedureNotPerformedReason(SNOMED-CT) (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

... category 1..1 CodeableConceptTW 處置/手術的分類。
Binding: ProcedureCategoryCodes(SNOMEDCT) (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


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://snomed.info/sct
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 399097000
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... code S 1..1 CodeableConceptTW 即為「麻醉模式」。
Binding: SNOMED CT Anesthesia值集 (required)
.... id 0..1 string 唯一可識別ID,以供資料項目間相互參照。
.... extension 0..* Extension 擴充的資料項目
Slice: Unordered, Open by value:url
.... Slices for coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。
Slice: Unordered, Open by pattern:$this
..... coding:loinc-procedures S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: LOINC處置或手術值集 (required)
..... coding:SCTAnesthesia S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。
Binding: SNOMED CT Anesthesia值集 (required)
.... text SΣ 0..1 string 概念的文字表示法
... subject SΣ 1..1 Reference(Patient IMRI) 處置/手術服務的對象
... encounter Σ 0..1 Reference(Encounter IMRI) 就醫(Encounter)紀錄作為處置/手術的一部分
... performed[x] SΣ 0..1 此處置/手術何時執行的?
.... performedDateTime dateTime S
.... performedPeriod Period
.... performedString string
.... performedAge Age
.... performedRange Range
... recorder Σ 0..1 Reference(Patient IMRI | Practitioner IMRI | PractitionerRole IMRI | RelatedPerson) 誰記錄此處置/手術
... asserter SΣ 0..1 Reference(Patient IMRI | Practitioner IMRI | PractitionerRole IMRI | RelatedPerson) 聲稱有此處置/手術的人
... performer SΣ 0..* BackboneElement 即為「麻醉醫師」,執行麻醉的人員
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... function 0..1 CodeableConceptTW 執行的型別
Binding: ProcedurePerformerRoleCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

.... actor SΣ 1..1 Reference(PractitionerRole IMRI) 參照至健康照護服務提供者
.... onBehalfOf S 0..1 Reference(Organization Hospital Department IMRI) 此裝置(Device)或健康照護服務提供者所屬機構(Organization)
... location Σ 0..1 Reference(Location IMRI) 處置/手術發生的地點(Location)?
... reasonCode 0..* CodeableConceptTW 處置/手術執行原因代碼
Binding: ProcedureReasonCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... reasonReference Σ 0..* Reference(ConditionChiefComplaint IMRI | ObservationLaboratory IMRI | DiagnosticReport | DocumentReference) 執行此處置/手術的原因
... bodySite S 0..* CodeableConceptTW 目標身體部位。
Binding: SNOMEDCTBodyStructures (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... outcome 0..1 CodeableConceptTW 處置/手術的結果。
Binding: ProcedureOutcomeCodes(SNOMEDCT) (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

... report 0..* Reference(DiagnosticReport | DocumentReference | CompositionOperationNote IMRI) 此處置/手術產生的任何報告
... complication 0..* CodeableConceptTW 處置/手術後的併發症
Binding: Condition/Problem/DiagnosisCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... complicationDetail 0..* Reference(ConditionComorbiditiesandComplications IMRI) 處置/手術後發生的病情、問題或診斷
... followUp 0..* CodeableConceptTW 追蹤說明。
Binding: ProcedureFollowUpCodes(SNOMEDCT) (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... note 0..* Annotation 關於此處置/手術的附加資訊
... focalDevice 0..* BackboneElement 處理、植入的或移除的裝置
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... action 0..1 CodeableConceptTW 改變裝置的種類
Binding: ProcedureDeviceActionCodes (preferred): 鼓勵使用所綁定值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。

.... manipulated 1..1 Reference(Device) 被改變的裝置
... usedReference 0..* Reference(Device | Medication | Substance) 處置/手術中使用的項目/物品
... usedCode 0..* CodeableConceptTW 處置/手術中使用的項目之代碼
Binding: FHIRDeviceTypes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。



doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Procedure.statusrequiredPattern: completed
http://hl7.org/fhir/ValueSet/event-status|4.0.1
from the FHIR Standard
Procedure.statusReasonextensibleProcedureNotPerformedReason(SNOMED-CT)
http://hl7.org/fhir/ValueSet/procedure-not-performed-reason
from the FHIR Standard
Procedure.categoryextensiblePattern: SNOMED-CT Code 399097000
http://hl7.org/fhir/ValueSet/procedure-category
from the FHIR Standard
Procedure.coderequiredSCTAnesthesia
https://hitstdio.ntunhs.edu.tw/imri/ValueSet/anesthesia-sct
from this IG
Procedure.code.coding:loinc-proceduresrequiredLOINCProcedureCodes (a valid code from LOINC)
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-procedure-code
Procedure.code.coding:SCTAnesthesiarequiredSCTAnesthesia
https://hitstdio.ntunhs.edu.tw/imri/ValueSet/anesthesia-sct
from this IG
Procedure.performer.functionextensibleProcedurePerformerRoleCodes
http://hl7.org/fhir/ValueSet/performer-role
from the FHIR Standard
Procedure.reasonCodeextensibleProcedureReasonCodes
http://hl7.org/fhir/ValueSet/procedure-reason
from the FHIR Standard
Procedure.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Procedure.outcomeextensibleProcedureOutcomeCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-outcome
from the FHIR Standard
Procedure.complicationextensibleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Procedure.followUpextensibleProcedureFollowUpCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-followup
from the FHIR Standard
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
http://hl7.org/fhir/ValueSet/device-action
from the FHIR Standard
Procedure.usedCodeextensibleFHIRDeviceTypes
http://hl7.org/fhir/ValueSet/device-kind
from the FHIR Standard

 

Other representations of profile: CSV, Excel, Schematron