醫療保險理賠實作指引
0.1.3 - CI Build

This page is part of the 醫療保險理賠實作指引 (v0.1.3: Releases Ballot 2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Resource Profile: DiagnosticReport iClaim

Official URL: https://claim.cgh.org.tw/iclaim/StructureDefinition/diagnosticreport-iclaim Version: 0.1.3
Active as of 2023-12-25 Computable Name: DiagnosticReportiClaim

DiagnosticReport iClaim Profile說明本IG如何進一步定義臺灣核心-診斷報告(TW Core DiagnosticReport) Profile以呈現診斷報告

Usage:

Formal Views of Profile Content

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

This structure is derived from TWCoreDiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport TWCoreDiagnosticReport
... status 1..1coderegistered | partial | preliminary | final +
Required Pattern: final
... category 0..1CodeableConceptTW服務類別
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: LAB
.... coding 1..1CodingTW由專門術語系統(terminology system)定義的代碼
... code 1..1CodeableConceptTW即為「檢驗報告名稱」,此診斷報告的名稱/代碼
Binding: LOINC實驗室檢驗檢查報告名稱值集 (required): 應填入LOINCObservationCategory代碼表中的其中一個代碼

.... coding 1..1CodingTW由專門術語系統(terminology system)定義的代碼
.... coding:LOINCObservationCode 0..1CodingTW由專門術語系統(terminology system)定義的代碼
Binding: LOINC實驗室檢驗檢查報告名稱值集 (required)
... encounter 0..1Reference(Encounter iClaim)請求檢驗時的健康照護事件
... performer 0..*Reference(Practitioner iClaim | PractitionerRole | TW Core Organization Hospital Department | CareTeam)對診斷服務負責者
... resultsInterpreter 0..*Reference(Practitioner iClaim | PractitionerRole | TW Core Organization Hospital Department | CareTeam)主要結果的解釋者
... result 1..*Reference(Observation iClaim)檢驗檢查

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
DiagnosticReport.coderequiredLOINCObservationCategory
DiagnosticReport.code.coding:LOINCObservationCoderequiredLOINCObservationCategory
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*TWCoreDiagnosticReport診斷報告—由請求資訊、不可被中斷的一個或一系列結果(atomic results)、影像、解釋以及格式化報告所組成。
... implicitRules ?!Σ0..1uri創建此內容所依據的一組規則
... text S0..1NarrativeDiagnosticReport Resource之內容摘要以供人閱讀
... 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。
... Slices for category SΣ0..1CodeableConceptTW服務類別
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): 可參考DiagnosticServiceSectionCodes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。



Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: LAB
.... category:All Slices Content/Rules for all slices
..... coding S1..1CodingTW由專門術語系統(terminology system)定義的代碼
..... text SΣ0..1string概念的文字表示法
.... category:DiagnosticServiceSectionCodes S0..1CodeableConceptTW概念(Concept)— 參照一個專門術語或只是文字表述
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: LAB
... code S1..1CodeableConceptTW即為「檢驗報告名稱」,此診斷報告的名稱/代碼
Binding: LOINC實驗室檢驗檢查報告名稱值集 (required): 應填入LOINCObservationCategory代碼表中的其中一個代碼

.... Slices for coding S1..1CodingTW由專門術語系統(terminology system)定義的代碼
Slice: Unordered, Open by pattern:system
..... coding:LOINCObservationCode S0..1CodingTW由專門術語系統(terminology system)定義的代碼
Binding: LOINC實驗室檢驗檢查報告名稱值集 (required)
...... system SΣ1..1uri專門術語系統(terminology system)的識別
Required Pattern: http://loinc.org
...... code SΣ1..1code系統定義的語法之符號
...... display SΣ0..1string由系統定義的表示法
..... coding:TWLaboratoryCategory S0..1CodingTW此為中央健康保險署(NHI)維護之醫療服務給付項目-檢驗相關代碼,主要針對申報使用,更新頻率相對頻繁,可免費使用,可依情境選用此代碼。
Binding: 臺灣醫療服務給付項目-檢驗值集 (required): 應填入臺灣醫療服務給付項目-檢驗值集值集中的其中一個代碼。


...... system SΣ1..1uri專門術語系統(terminology system)的識別
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-service-payment-tw
...... code SΣ1..1code系統定義的語法之符號
...... display SΣ0..1string由系統定義的表示法
.... text SΣ0..1string概念的文字表示法
... subject SΣ0..1Reference(Patient iClaim | Group | Device | Location)報告的對象—通常但不總是病人
... encounter Σ0..1Reference(Encounter iClaim)請求檢驗時的健康照護事件
... effective[x] SΣ0..1與臨床相關的時間/報告的時段
.... effectiveDateTimedateTime
... issued SΣ0..1instant此版本完成的日期時間
... performer SΣ0..*Reference(Practitioner iClaim | PractitionerRole | TW Core Organization Hospital Department | CareTeam)對診斷服務負責者
... resultsInterpreter Σ0..*Reference(Practitioner iClaim | PractitionerRole | TW Core Organization Hospital Department | CareTeam)主要結果的解釋者
... result S1..*Reference(Observation iClaim)檢驗檢查
... conclusion S0..1string檢驗結果的臨床結論(解釋)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
DiagnosticReport.statusrequiredPattern: final
DiagnosticReport.categoryexamplePattern: LAB
DiagnosticReport.category:DiagnosticServiceSectionCodesexamplePattern: LAB
DiagnosticReport.coderequiredLOINCObservationCategory
DiagnosticReport.code.coding:LOINCObservationCoderequiredLOINCObservationCategory
DiagnosticReport.code.coding:TWLaboratoryCategoryrequiredTWLaboratoryCategory
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*TWCoreDiagnosticReport診斷報告—由請求資訊、不可被中斷的一個或一系列結果(atomic results)、影像、解釋以及格式化報告所組成。
... id Σ0..1id不重複的ID用以識別儲存在特定FHIR Server中的DiagnosticReport紀錄,通常又稱為邏輯性ID。
... meta Σ0..1Meta此DiagnosticReport Resource的metadata
... implicitRules ?!Σ0..1uri創建此內容所依據的一組規則
... text S0..1NarrativeDiagnosticReport 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 Σ0..*Identifier報告的業務用識別碼
... basedOn 0..*Reference(CarePlan | ImmunizationRecommendation | TW Core MedicationRequest | NutritionOrder | ServiceRequest)此報告是基於什麼服務的請求
... status ?!SΣ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): 診斷報告狀態;應填入DiagnosticReportStatus值集中的其中一個代碼


Required Pattern: final
... Slices for category SΣ0..1CodeableConceptTW服務類別
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): 可參考DiagnosticServiceSectionCodes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。



Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: LAB
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
.... category:All Slices Content/Rules for all slices
..... id 0..1string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
..... coding S1..1CodingTW由專門術語系統(terminology system)定義的代碼
..... text SΣ0..1string概念的文字表示法
.... category:DiagnosticServiceSectionCodes S0..1CodeableConceptTW概念(Concept)— 參照一個專門術語或只是文字表述
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: LAB
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
... code S1..1CodeableConceptTW即為「檢驗報告名稱」,此診斷報告的名稱/代碼
Binding: LOINC實驗室檢驗檢查報告名稱值集 (required): 應填入LOINCObservationCategory代碼表中的其中一個代碼

.... id 0..1string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 S1..1CodingTW由專門術語系統(terminology system)定義的代碼
Slice: Unordered, Open by pattern:system
..... coding:LOINCObservationCode S0..1CodingTW由專門術語系統(terminology system)定義的代碼
Binding: LOINC實驗室檢驗檢查報告名稱值集 (required)
...... id 0..1string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
...... system SΣ1..1uri專門術語系統(terminology system)的識別
Required Pattern: http://loinc.org
...... version Σ0..1string系統的版本—如果相關的話
...... code SΣ1..1code系統定義的語法之符號
...... display SΣ0..1string由系統定義的表示法
...... userSelected Σ0..1boolean此編碼是否由使用者直接選擇?
..... coding:TWLaboratoryCategory S0..1CodingTW此為中央健康保險署(NHI)維護之醫療服務給付項目-檢驗相關代碼,主要針對申報使用,更新頻率相對頻繁,可免費使用,可依情境選用此代碼。
Binding: 臺灣醫療服務給付項目-檢驗值集 (required): 應填入臺灣醫療服務給付項目-檢驗值集值集中的其中一個代碼。


...... id 0..1string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
...... system SΣ1..1uri專門術語系統(terminology system)的識別
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-service-payment-tw
...... version Σ0..1string系統的版本—如果相關的話
...... code SΣ1..1code系統定義的語法之符號
...... display SΣ0..1string由系統定義的表示法
...... userSelected Σ0..1boolean此編碼是否由使用者直接選擇?
.... text SΣ0..1string概念的文字表示法
... subject SΣ0..1Reference(Patient iClaim | Group | Device | Location)報告的對象—通常但不總是病人
... encounter Σ0..1Reference(Encounter iClaim)請求檢驗時的健康照護事件
... effective[x] SΣ0..1與臨床相關的時間/報告的時段
.... effectiveDateTimedateTime S
.... effectivePeriodPeriod
... issued SΣ0..1instant此版本完成的日期時間
... performer SΣ0..*Reference(Practitioner iClaim | PractitionerRole | TW Core Organization Hospital Department | CareTeam)對診斷服務負責者
... resultsInterpreter Σ0..*Reference(Practitioner iClaim | PractitionerRole | TW Core Organization Hospital Department | CareTeam)主要結果的解釋者
... specimen 0..*Reference(Specimen)此報告所依據的檢體
... result S1..*Reference(Observation iClaim)檢驗檢查
... imagingStudy 0..*Reference(ImagingStudy)參照至與診斷報告相關的成像之全部細節
... media Σ0..*BackboneElement與此報告相關的關鍵影像
.... id 0..1string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
.... modifierExtension ?!Σ0..*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。
.... comment 0..1string關於影像的意見(例如:解釋)。
.... link Σ1..1Reference(Media)參照的影像來源
... conclusion S0..1string檢驗結果的臨床結論(解釋)
... conclusionCode 0..*CodeableConceptTW檢驗結果的臨床結論的代碼,此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。
Binding: SNOMEDCTClinicalFindings (example): 可參考SNOMEDCTClinicalFindings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。


... presentedForm 0..*Attachment已發佈的整個報告

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DiagnosticReport.statusrequiredPattern: final
DiagnosticReport.categoryexamplePattern: LAB
DiagnosticReport.category:DiagnosticServiceSectionCodesexamplePattern: LAB
DiagnosticReport.coderequiredLOINCObservationCategory
DiagnosticReport.code.coding:LOINCObservationCoderequiredLOINCObservationCategory
DiagnosticReport.code.coding:TWLaboratoryCategoryrequiredTWLaboratoryCategory
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings

Differential View

This structure is derived from TWCoreDiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport TWCoreDiagnosticReport
... status 1..1coderegistered | partial | preliminary | final +
Required Pattern: final
... category 0..1CodeableConceptTW服務類別
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: LAB
.... coding 1..1CodingTW由專門術語系統(terminology system)定義的代碼
... code 1..1CodeableConceptTW即為「檢驗報告名稱」,此診斷報告的名稱/代碼
Binding: LOINC實驗室檢驗檢查報告名稱值集 (required): 應填入LOINCObservationCategory代碼表中的其中一個代碼

.... coding 1..1CodingTW由專門術語系統(terminology system)定義的代碼
.... coding:LOINCObservationCode 0..1CodingTW由專門術語系統(terminology system)定義的代碼
Binding: LOINC實驗室檢驗檢查報告名稱值集 (required)
... encounter 0..1Reference(Encounter iClaim)請求檢驗時的健康照護事件
... performer 0..*Reference(Practitioner iClaim | PractitionerRole | TW Core Organization Hospital Department | CareTeam)對診斷服務負責者
... resultsInterpreter 0..*Reference(Practitioner iClaim | PractitionerRole | TW Core Organization Hospital Department | CareTeam)主要結果的解釋者
... result 1..*Reference(Observation iClaim)檢驗檢查

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
DiagnosticReport.coderequiredLOINCObservationCategory
DiagnosticReport.code.coding:LOINCObservationCoderequiredLOINCObservationCategory

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*TWCoreDiagnosticReport診斷報告—由請求資訊、不可被中斷的一個或一系列結果(atomic results)、影像、解釋以及格式化報告所組成。
... implicitRules ?!Σ0..1uri創建此內容所依據的一組規則
... text S0..1NarrativeDiagnosticReport Resource之內容摘要以供人閱讀
... 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。
... Slices for category SΣ0..1CodeableConceptTW服務類別
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): 可參考DiagnosticServiceSectionCodes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。



Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: LAB
.... category:All Slices Content/Rules for all slices
..... coding S1..1CodingTW由專門術語系統(terminology system)定義的代碼
..... text SΣ0..1string概念的文字表示法
.... category:DiagnosticServiceSectionCodes S0..1CodeableConceptTW概念(Concept)— 參照一個專門術語或只是文字表述
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: LAB
... code S1..1CodeableConceptTW即為「檢驗報告名稱」,此診斷報告的名稱/代碼
Binding: LOINC實驗室檢驗檢查報告名稱值集 (required): 應填入LOINCObservationCategory代碼表中的其中一個代碼

.... Slices for coding S1..1CodingTW由專門術語系統(terminology system)定義的代碼
Slice: Unordered, Open by pattern:system
..... coding:LOINCObservationCode S0..1CodingTW由專門術語系統(terminology system)定義的代碼
Binding: LOINC實驗室檢驗檢查報告名稱值集 (required)
...... system SΣ1..1uri專門術語系統(terminology system)的識別
Required Pattern: http://loinc.org
...... code SΣ1..1code系統定義的語法之符號
...... display SΣ0..1string由系統定義的表示法
..... coding:TWLaboratoryCategory S0..1CodingTW此為中央健康保險署(NHI)維護之醫療服務給付項目-檢驗相關代碼,主要針對申報使用,更新頻率相對頻繁,可免費使用,可依情境選用此代碼。
Binding: 臺灣醫療服務給付項目-檢驗值集 (required): 應填入臺灣醫療服務給付項目-檢驗值集值集中的其中一個代碼。


...... system SΣ1..1uri專門術語系統(terminology system)的識別
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-service-payment-tw
...... code SΣ1..1code系統定義的語法之符號
...... display SΣ0..1string由系統定義的表示法
.... text SΣ0..1string概念的文字表示法
... subject SΣ0..1Reference(Patient iClaim | Group | Device | Location)報告的對象—通常但不總是病人
... encounter Σ0..1Reference(Encounter iClaim)請求檢驗時的健康照護事件
... effective[x] SΣ0..1與臨床相關的時間/報告的時段
.... effectiveDateTimedateTime
... issued SΣ0..1instant此版本完成的日期時間
... performer SΣ0..*Reference(Practitioner iClaim | PractitionerRole | TW Core Organization Hospital Department | CareTeam)對診斷服務負責者
... resultsInterpreter Σ0..*Reference(Practitioner iClaim | PractitionerRole | TW Core Organization Hospital Department | CareTeam)主要結果的解釋者
... result S1..*Reference(Observation iClaim)檢驗檢查
... conclusion S0..1string檢驗結果的臨床結論(解釋)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
DiagnosticReport.statusrequiredPattern: final
DiagnosticReport.categoryexamplePattern: LAB
DiagnosticReport.category:DiagnosticServiceSectionCodesexamplePattern: LAB
DiagnosticReport.coderequiredLOINCObservationCategory
DiagnosticReport.code.coding:LOINCObservationCoderequiredLOINCObservationCategory
DiagnosticReport.code.coding:TWLaboratoryCategoryrequiredTWLaboratoryCategory

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*TWCoreDiagnosticReport診斷報告—由請求資訊、不可被中斷的一個或一系列結果(atomic results)、影像、解釋以及格式化報告所組成。
... id Σ0..1id不重複的ID用以識別儲存在特定FHIR Server中的DiagnosticReport紀錄,通常又稱為邏輯性ID。
... meta Σ0..1Meta此DiagnosticReport Resource的metadata
... implicitRules ?!Σ0..1uri創建此內容所依據的一組規則
... text S0..1NarrativeDiagnosticReport 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 Σ0..*Identifier報告的業務用識別碼
... basedOn 0..*Reference(CarePlan | ImmunizationRecommendation | TW Core MedicationRequest | NutritionOrder | ServiceRequest)此報告是基於什麼服務的請求
... status ?!SΣ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): 診斷報告狀態;應填入DiagnosticReportStatus值集中的其中一個代碼


Required Pattern: final
... Slices for category SΣ0..1CodeableConceptTW服務類別
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): 可參考DiagnosticServiceSectionCodes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。



Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: LAB
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
.... category:All Slices Content/Rules for all slices
..... id 0..1string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
..... coding S1..1CodingTW由專門術語系統(terminology system)定義的代碼
..... text SΣ0..1string概念的文字表示法
.... category:DiagnosticServiceSectionCodes S0..1CodeableConceptTW概念(Concept)— 參照一個專門術語或只是文字表述
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: LAB
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
... code S1..1CodeableConceptTW即為「檢驗報告名稱」,此診斷報告的名稱/代碼
Binding: LOINC實驗室檢驗檢查報告名稱值集 (required): 應填入LOINCObservationCategory代碼表中的其中一個代碼

.... id 0..1string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 S1..1CodingTW由專門術語系統(terminology system)定義的代碼
Slice: Unordered, Open by pattern:system
..... coding:LOINCObservationCode S0..1CodingTW由專門術語系統(terminology system)定義的代碼
Binding: LOINC實驗室檢驗檢查報告名稱值集 (required)
...... id 0..1string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
...... system SΣ1..1uri專門術語系統(terminology system)的識別
Required Pattern: http://loinc.org
...... version Σ0..1string系統的版本—如果相關的話
...... code SΣ1..1code系統定義的語法之符號
...... display SΣ0..1string由系統定義的表示法
...... userSelected Σ0..1boolean此編碼是否由使用者直接選擇?
..... coding:TWLaboratoryCategory S0..1CodingTW此為中央健康保險署(NHI)維護之醫療服務給付項目-檢驗相關代碼,主要針對申報使用,更新頻率相對頻繁,可免費使用,可依情境選用此代碼。
Binding: 臺灣醫療服務給付項目-檢驗值集 (required): 應填入臺灣醫療服務給付項目-檢驗值集值集中的其中一個代碼。


...... id 0..1string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
...... system SΣ1..1uri專門術語系統(terminology system)的識別
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-service-payment-tw
...... version Σ0..1string系統的版本—如果相關的話
...... code SΣ1..1code系統定義的語法之符號
...... display SΣ0..1string由系統定義的表示法
...... userSelected Σ0..1boolean此編碼是否由使用者直接選擇?
.... text SΣ0..1string概念的文字表示法
... subject SΣ0..1Reference(Patient iClaim | Group | Device | Location)報告的對象—通常但不總是病人
... encounter Σ0..1Reference(Encounter iClaim)請求檢驗時的健康照護事件
... effective[x] SΣ0..1與臨床相關的時間/報告的時段
.... effectiveDateTimedateTime S
.... effectivePeriodPeriod
... issued SΣ0..1instant此版本完成的日期時間
... performer SΣ0..*Reference(Practitioner iClaim | PractitionerRole | TW Core Organization Hospital Department | CareTeam)對診斷服務負責者
... resultsInterpreter Σ0..*Reference(Practitioner iClaim | PractitionerRole | TW Core Organization Hospital Department | CareTeam)主要結果的解釋者
... specimen 0..*Reference(Specimen)此報告所依據的檢體
... result S1..*Reference(Observation iClaim)檢驗檢查
... imagingStudy 0..*Reference(ImagingStudy)參照至與診斷報告相關的成像之全部細節
... media Σ0..*BackboneElement與此報告相關的關鍵影像
.... id 0..1string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
.... modifierExtension ?!Σ0..*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。
.... comment 0..1string關於影像的意見(例如:解釋)。
.... link Σ1..1Reference(Media)參照的影像來源
... conclusion S0..1string檢驗結果的臨床結論(解釋)
... conclusionCode 0..*CodeableConceptTW檢驗結果的臨床結論的代碼,此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。
Binding: SNOMEDCTClinicalFindings (example): 可參考SNOMEDCTClinicalFindings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。


... presentedForm 0..*Attachment已發佈的整個報告

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DiagnosticReport.statusrequiredPattern: final
DiagnosticReport.categoryexamplePattern: LAB
DiagnosticReport.category:DiagnosticServiceSectionCodesexamplePattern: LAB
DiagnosticReport.coderequiredLOINCObservationCategory
DiagnosticReport.code.coding:LOINCObservationCoderequiredLOINCObservationCategory
DiagnosticReport.code.coding:TWLaboratoryCategoryrequiredTWLaboratoryCategory
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings

 

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