醫查實作指引 - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
Official URL: https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/procedure-imri | Version: 0.1.0 | |||
Active as of 2024-08-12 | Computable Name: ProcedureIMRI |
此處置或手術(Procedure 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以呈現處置或手術的詳細資料。
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from TWCoreProcedure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 |
partOf | Σ | 0..* | Reference(Procedure IMRI | ObservationLaboratory IMRI | MedicationAdministration) | 參照事件的一部分 |
status | ?!SΣ | 1..1 | code | preparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknown Binding: EventStatus (required): 應填入所綁定值集中的其中一個代碼 Required Pattern: completed |
category | 0..1 | CodeableConceptTW | 處置/手術的分類。 Binding: ProcedureCategoryCodes(SNOMEDCT) (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 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: 8724-7 | |
code | S | 1..1 | CodeableConceptTW | 即為「手術方法」,處置/手術的識別碼。 Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . |
Slices for coding | S | 0..* | CodingTW | 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 Slice: Unordered, Open by pattern:$this |
coding:icd10-pcs-2021 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署(NHI)維護之2021年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2021年中文版ICD-10-PCS值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 |
coding:icd10-pcs-2014 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署(NHI)維護之2014年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2014年中文版ICD-10-PCS值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 |
coding:medical-service-payment | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署(NHI)維護之醫療服務給付項目,主要針對申報使用,可免費使用,可依情境選用此代碼。 Binding: 臺灣健保署醫療服務給付項目-處置或手術值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 |
coding:sct-procedures | S | 0..1 | CodingTW | 此為SNOMED CT處置/手術代碼,若機構已有購買相關授權,亦可使用。 Binding: ProcedureCodes(SNOMEDCT) (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 |
coding:loinc-procedures | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: LOINC處置或手術值集 (required) |
text | SΣ | 1..1 | string | 概念的文字表示法 |
subject | SΣ | 1..1 | Reference(Patient IMRI) | 處置/手術服務的對象 |
encounter | Σ | 0..1 | Reference(Encounter IMRI) | 就醫(Encounter)紀錄作為處置/手術的一部分 |
Slices for performed[x] | SΣ | 1..1 | dateTime | 即為「手術日期」,此處置何時執行的?。 Slice: Unordered, Closed by type:$this |
performed[x]:performedDateTime | SΣ | 1..1 | dateTime | 此處置/手術何時執行的? |
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 | 執行處置/手術的人員 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
actor | SΣ | 1..1 | Reference(Practitioner IMRI | PractitionerRole IMRI | Organization Hospital Department IMRI | Patient IMRI | RelatedPerson | Device) | 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 | |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Procedure.status | required | Pattern: completedhttp://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard | |
Procedure.category | extensible | Pattern: LOINC Code 8724-7http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard | |
Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | |
Procedure.code.coding:icd10-pcs-2021 | required | TW2021ICD10PCShttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw | |
Procedure.code.coding:icd10-pcs-2014 | required | TW2014ICD10PCShttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2014-tw | |
Procedure.code.coding:medical-service-payment | required | TWMedicalServicePaymenthttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/procedure-tw | |
Procedure.code.coding:sct-procedures | required | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | |
Procedure.code.coding:loinc-procedures | required | LOINCProcedureCodes (a valid code from LOINC)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-procedure-code | |
Procedure.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Procedure | 0..* | TWCoreProcedure | 正在或曾經對病人執行的動作 | |||||
id | Σ | 0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的Procedure紀錄,通常又稱為邏輯性ID。 | ||||
meta | Σ | 0..1 | Meta | 此Procedure Resource的metadata | ||||
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 | ||||
language | 0..1 | code | 用以表述Procedure Resource內容的語言。 Binding: CommonLanguages (preferred): 人類語言;鼓勵使用CommonLanguages代碼表中的代碼,但不強制一定要使用此代碼表,你也可使用其他代碼表的代碼或單純以文字表示。
Example Value: zh-TW | |||||
text | 0..1 | Narrative | Procedure Resource之內容摘要以供人閱讀 | |||||
contained | 0..* | Resource | 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(Procedure IMRI | ObservationLaboratory IMRI | MedicationAdministration) | 參照事件的一部分 | ||||
status | ?!SΣ | 1..1 | code | preparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknown Binding: EventStatus (required): 應填入所綁定值集中的其中一個代碼 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 | 0..1 | CodeableConceptTW | 處置/手術的分類。 Binding: ProcedureCategoryCodes(SNOMEDCT) (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 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: 8724-7 | |||||
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「手術方法」,處置/手術的識別碼。 Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . | ||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 Slice: Unordered, Open by value:url | |||||
Slices for coding | S | 0..* | CodingTW | 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 Slice: Unordered, Open by pattern:$this | ||||
coding:icd10-pcs-2021 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署(NHI)維護之2021年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2021年中文版ICD-10-PCS值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:icd10-pcs-2014 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署(NHI)維護之2014年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2014年中文版ICD-10-PCS值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:medical-service-payment | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署(NHI)維護之醫療服務給付項目,主要針對申報使用,可免費使用,可依情境選用此代碼。 Binding: 臺灣健保署醫療服務給付項目-處置或手術值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:sct-procedures | S | 0..1 | CodingTW | 此為SNOMED CT處置/手術代碼,若機構已有購買相關授權,亦可使用。 Binding: ProcedureCodes(SNOMEDCT) (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:loinc-procedures | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: LOINC處置或手術值集 (required) | ||||
text | SΣ | 1..1 | string | 概念的文字表示法 | ||||
subject | SΣ | 1..1 | Reference(Patient IMRI) | 處置/手術服務的對象 | ||||
encounter | Σ | 0..1 | Reference(Encounter IMRI) | 就醫(Encounter)紀錄作為處置/手術的一部分 | ||||
Slices for performed[x] | SΣ | 1..1 | dateTime S | 即為「手術日期」,此處置何時執行的?。 Slice: Unordered, Closed by type:$this | ||||
performed[x]:performedDateTime | SΣ | 1..1 | dateTime S | 此處置/手術何時執行的? | ||||
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 | 執行處置/手術的人員 | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
function | 0..1 | CodeableConceptTW | 執行的型別 Binding: ProcedurePerformerRoleCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | |||||
actor | SΣ | 1..1 | Reference(Practitioner IMRI | PractitionerRole IMRI | Organization Hospital Department IMRI | Patient IMRI | RelatedPerson | Device) | 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。 | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Procedure.status | required | Pattern: completedhttp://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard | ||||
Procedure.statusReason | extensible | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard | ||||
Procedure.category | extensible | Pattern: LOINC Code 8724-7http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard | ||||
Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | ||||
Procedure.code.coding:icd10-pcs-2021 | required | TW2021ICD10PCShttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw | ||||
Procedure.code.coding:icd10-pcs-2014 | required | TW2014ICD10PCShttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2014-tw | ||||
Procedure.code.coding:medical-service-payment | required | TWMedicalServicePaymenthttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/procedure-tw | ||||
Procedure.code.coding:sct-procedures | required | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | ||||
Procedure.code.coding:loinc-procedures | required | LOINCProcedureCodes (a valid code from LOINC)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-procedure-code | ||||
Procedure.performer.function | extensible | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard | ||||
Procedure.reasonCode | extensible | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard | ||||
Procedure.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Procedure.outcome | extensible | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard | ||||
Procedure.complication | extensible | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Procedure.followUp | extensible | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard | ||||
Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-action from the FHIR Standard | ||||
Procedure.usedCode | extensible | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard |
This structure is derived from TWCoreProcedure
Summary
Mandatory: 3 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from TWCoreProcedure
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | 0..* | TWCoreProcedure | 正在或曾經對病人執行的動作 | |
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 |
partOf | Σ | 0..* | Reference(Procedure IMRI | ObservationLaboratory IMRI | MedicationAdministration) | 參照事件的一部分 |
status | ?!SΣ | 1..1 | code | preparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknown Binding: EventStatus (required): 應填入所綁定值集中的其中一個代碼 Required Pattern: completed |
category | 0..1 | CodeableConceptTW | 處置/手術的分類。 Binding: ProcedureCategoryCodes(SNOMEDCT) (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 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: 8724-7 | |
code | S | 1..1 | CodeableConceptTW | 即為「手術方法」,處置/手術的識別碼。 Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . |
Slices for coding | S | 0..* | CodingTW | 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 Slice: Unordered, Open by pattern:$this |
coding:icd10-pcs-2021 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署(NHI)維護之2021年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2021年中文版ICD-10-PCS值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 |
coding:icd10-pcs-2014 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署(NHI)維護之2014年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2014年中文版ICD-10-PCS值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 |
coding:medical-service-payment | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署(NHI)維護之醫療服務給付項目,主要針對申報使用,可免費使用,可依情境選用此代碼。 Binding: 臺灣健保署醫療服務給付項目-處置或手術值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 |
coding:sct-procedures | S | 0..1 | CodingTW | 此為SNOMED CT處置/手術代碼,若機構已有購買相關授權,亦可使用。 Binding: ProcedureCodes(SNOMEDCT) (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 |
coding:loinc-procedures | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: LOINC處置或手術值集 (required) |
text | SΣ | 1..1 | string | 概念的文字表示法 |
subject | SΣ | 1..1 | Reference(Patient IMRI) | 處置/手術服務的對象 |
encounter | Σ | 0..1 | Reference(Encounter IMRI) | 就醫(Encounter)紀錄作為處置/手術的一部分 |
Slices for performed[x] | SΣ | 1..1 | dateTime | 即為「手術日期」,此處置何時執行的?。 Slice: Unordered, Closed by type:$this |
performed[x]:performedDateTime | SΣ | 1..1 | dateTime | 此處置/手術何時執行的? |
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 | 執行處置/手術的人員 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
actor | SΣ | 1..1 | Reference(Practitioner IMRI | PractitionerRole IMRI | Organization Hospital Department IMRI | Patient IMRI | RelatedPerson | Device) | 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 | |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Procedure.status | required | Pattern: completedhttp://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard | |
Procedure.category | extensible | Pattern: LOINC Code 8724-7http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard | |
Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | |
Procedure.code.coding:icd10-pcs-2021 | required | TW2021ICD10PCShttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw | |
Procedure.code.coding:icd10-pcs-2014 | required | TW2014ICD10PCShttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2014-tw | |
Procedure.code.coding:medical-service-payment | required | TWMedicalServicePaymenthttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/procedure-tw | |
Procedure.code.coding:sct-procedures | required | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | |
Procedure.code.coding:loinc-procedures | required | LOINCProcedureCodes (a valid code from LOINC)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-procedure-code | |
Procedure.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Procedure | 0..* | TWCoreProcedure | 正在或曾經對病人執行的動作 | |||||
id | Σ | 0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的Procedure紀錄,通常又稱為邏輯性ID。 | ||||
meta | Σ | 0..1 | Meta | 此Procedure Resource的metadata | ||||
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 | ||||
language | 0..1 | code | 用以表述Procedure Resource內容的語言。 Binding: CommonLanguages (preferred): 人類語言;鼓勵使用CommonLanguages代碼表中的代碼,但不強制一定要使用此代碼表,你也可使用其他代碼表的代碼或單純以文字表示。
Example Value: zh-TW | |||||
text | 0..1 | Narrative | Procedure Resource之內容摘要以供人閱讀 | |||||
contained | 0..* | Resource | 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(Procedure IMRI | ObservationLaboratory IMRI | MedicationAdministration) | 參照事件的一部分 | ||||
status | ?!SΣ | 1..1 | code | preparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknown Binding: EventStatus (required): 應填入所綁定值集中的其中一個代碼 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 | 0..1 | CodeableConceptTW | 處置/手術的分類。 Binding: ProcedureCategoryCodes(SNOMEDCT) (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 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: 8724-7 | |||||
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「手術方法」,處置/手術的識別碼。 Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . | ||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 Slice: Unordered, Open by value:url | |||||
Slices for coding | S | 0..* | CodingTW | 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 Slice: Unordered, Open by pattern:$this | ||||
coding:icd10-pcs-2021 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署(NHI)維護之2021年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2021年中文版ICD-10-PCS值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:icd10-pcs-2014 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署(NHI)維護之2014年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2014年中文版ICD-10-PCS值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:medical-service-payment | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署(NHI)維護之醫療服務給付項目,主要針對申報使用,可免費使用,可依情境選用此代碼。 Binding: 臺灣健保署醫療服務給付項目-處置或手術值集 (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:sct-procedures | S | 0..1 | CodingTW | 此為SNOMED CT處置/手術代碼,若機構已有購買相關授權,亦可使用。 Binding: ProcedureCodes(SNOMEDCT) (required): 處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:loinc-procedures | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: LOINC處置或手術值集 (required) | ||||
text | SΣ | 1..1 | string | 概念的文字表示法 | ||||
subject | SΣ | 1..1 | Reference(Patient IMRI) | 處置/手術服務的對象 | ||||
encounter | Σ | 0..1 | Reference(Encounter IMRI) | 就醫(Encounter)紀錄作為處置/手術的一部分 | ||||
Slices for performed[x] | SΣ | 1..1 | dateTime S | 即為「手術日期」,此處置何時執行的?。 Slice: Unordered, Closed by type:$this | ||||
performed[x]:performedDateTime | SΣ | 1..1 | dateTime S | 此處置/手術何時執行的? | ||||
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 | 執行處置/手術的人員 | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
function | 0..1 | CodeableConceptTW | 執行的型別 Binding: ProcedurePerformerRoleCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | |||||
actor | SΣ | 1..1 | Reference(Practitioner IMRI | PractitionerRole IMRI | Organization Hospital Department IMRI | Patient IMRI | RelatedPerson | Device) | 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。 | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Procedure.status | required | Pattern: completedhttp://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard | ||||
Procedure.statusReason | extensible | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard | ||||
Procedure.category | extensible | Pattern: LOINC Code 8724-7http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard | ||||
Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | ||||
Procedure.code.coding:icd10-pcs-2021 | required | TW2021ICD10PCShttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw | ||||
Procedure.code.coding:icd10-pcs-2014 | required | TW2014ICD10PCShttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2014-tw | ||||
Procedure.code.coding:medical-service-payment | required | TWMedicalServicePaymenthttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/procedure-tw | ||||
Procedure.code.coding:sct-procedures | required | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | ||||
Procedure.code.coding:loinc-procedures | required | LOINCProcedureCodes (a valid code from LOINC)https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-procedure-code | ||||
Procedure.performer.function | extensible | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard | ||||
Procedure.reasonCode | extensible | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard | ||||
Procedure.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Procedure.outcome | extensible | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard | ||||
Procedure.complication | extensible | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Procedure.followUp | extensible | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard | ||||
Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-action from the FHIR Standard | ||||
Procedure.usedCode | extensible | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard |
This structure is derived from TWCoreProcedure
Summary
Mandatory: 3 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron