電子病歷交換單張實作指引(EMR-IG)
0.1.0 - ci-build
This page is part of the 電子病歷交換單張實作指引(EMR-IG) (v0.1.0: Releases) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
| Draft as of 2023-10-11 |
Definitions for the IMAGE logical model.
Guidance on how to interpret the contents of this table can be found here
| 0. IMAGE | |
| Definition | Medical Imaging And Report |
| Short | 此邏輯模型適用於醫學影像報告 |
| Logical Model | Instances of this logical model are not marked to be the target of a Reference |
| 2. IMAGE.hospitaltype | |
| Definition | 醫院別 |
| Short | 醫院別 |
| Control | 1..1 |
| Type | Base |
| 4. IMAGE.hospitaltype.id | |
| Definition | 醫事機構代碼，院所代碼需與健保申報相同 |
| Short | 醫事機構代碼，院所代碼需與健保申報相同 |
| Control | 1..1 |
| Type | Identifier |
| 6. IMAGE.hospitaltype.name | |
| Definition | 醫事機構名稱，院所名稱需與健保申報相同 |
| Short | 醫事機構名稱，院所名稱需與健保申報相同 |
| Control | 1..1 |
| Type | string |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 8. IMAGE.order | |
| Definition | 檢查項目 |
| Short | 檢查項目 |
| Control | 1..1 |
| Type | Base |
| 10. IMAGE.order.code | |
| Definition | 醫令代碼，檢查健保醫令代碼，需與健保申報相同。 |
| Short | 醫令代碼，檢查健保醫令代碼，需與健保申報相同。 |
| Control | 1..1 |
| Type | CodeableConcept |
| 12. IMAGE.order.description | |
| Definition | 醫令名稱，檢查健保醫令名稱，需與健保申報相同。 |
| Short | 醫令名稱，檢查健保醫令名稱，需與健保申報相同。 |
| Control | 1..1 |
| Type | string |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 14. IMAGE.examinationStatus | |
| Definition | 檢查部位 |
| Short | 檢查部位 |
| Control | 1..1 |
| Type | Base |
| 16. IMAGE.examinationStatus.physicalExamination | |
| Definition | 檢查部位，檢查部位，需與健保申報相同。 |
| Short | 檢查部位，檢查部位，需與健保申報相同。 |
| Control | 1..* |
| Type | Coding |
| 18. IMAGE.examinationStatus.description | |
| Definition | 檢查部位詳細說明、拍攝方向與角度等 |
| Short | 檢查部位詳細說明、拍攝方向與角度等 |
| Control | 0..1 |
| Type | string |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 20. IMAGE.numberOfInstances | |
| Definition | 檢查張數 |
| Short | 檢查張數 |
| Control | 1..* |
| Type | unsignedInt |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 22. IMAGE.accessionNo | |
| Definition | 檢查單號，須與影像資料串連，每筆檢查必須有獨立不重複的單號。 |
| Short | 檢查單號，須與影像資料串連，每筆檢查必須有獨立不重複的單號。 |
| Control | 1..1 |
| Type | Identifier |
| 24. IMAGE.patientInformation | |
| Definition | 病人基本資料 |
| Short | 病人基本資料 |
| Control | 1..1 |
| Type | Base |
| 26. IMAGE.patientInformation.idNumber | |
| Definition | 身分證號，病人身分證號。 |
| Short | 身分證號，病人身分證號。 |
| Control | 1..1 |
| Type | Identifier |
| 28. IMAGE.patientInformation.chartNO | |
| Definition | 病歷號碼，院內病歷號碼。 |
| Short | 病歷號碼，院內病歷號碼。 |
| Control | 1..1 |
| Type | Identifier |
| 30. IMAGE.patientInformation.name | |
| Definition | 姓名 |
| Short | 姓名 |
| Control | 1..1 |
| Type | string |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 32. IMAGE.patientInformation.administrativeSex | |
| Definition | 性別 |
| Short | 性別 |
| Control | 1..1 |
| Type | code |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 34. IMAGE.patientInformation.birthDate | |
| Definition | 出生日期 |
| Short | 出生日期 |
| Control | 1..1 |
| Type | date |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 36. IMAGE.medicalOrder | |
| Definition | 醫囑時間及醫囑醫師資料 |
| Short | 醫囑時間及醫囑醫師資料 |
| Control | 1..1 |
| Type | Base |
| 38. IMAGE.medicalOrder.orderDatetime | |
| Definition | 醫囑時間，醫囑日期（分），格式為西元YYYYMMDDHHMM。 |
| Short | 醫囑時間，醫囑日期（分），格式為西元YYYYMMDDHHMM。 |
| Control | 1..1 |
| Type | Period |
| 40. IMAGE.medicalOrder.orderPhysician | |
| Definition | 醫囑醫師姓名 |
| Short | 醫囑醫師姓名 |
| Control | 1..1 |
| Type | Practitioner |
| 42. IMAGE.historyOfPresentIllness | |
| Definition | 病史，病人病史，內容可以包含主訴、適應症等。 |
| Short | 病史，病人病史，內容可以包含主訴、適應症等。 |
| Control | 1..* |
| Type | CodeableConcept |
| 44. IMAGE.diagnosisICDcode | |
| Definition | 疾病診斷，疾病診斷代碼及文字。 |
| Short | 疾病診斷，疾病診斷代碼及文字。 |
| Control | 0..* |
| Type | CodeableConcept |
| 46. IMAGE.examDatetime | |
| Definition | 實際檢查日期時間(分) ，格式為西元YYYYMMDDHHMM。 |
| Short | 實際檢查日期時間(分) ，格式為西元YYYYMMDDHHMM。 |
| Control | 1..1 |
| Type | dateTime |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 48. IMAGE.picture | |
| Definition | 圖片 |
| Short | 圖片 |
| Control | 1..* |
| Type | ImagingStudy |
| 50. IMAGE.recordTotal | |
| Definition | 報告結果，含影像發現、臆斷及註記(如過敏反應、顯影劑種類等)。 |
| Short | 報告結果，含影像發現、臆斷及註記(如過敏反應、顯影劑種類等)。 |
| Control | 1..* |
| Type | string |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 52. IMAGE.radiologyStudyRecommendation | |
| Definition | 醫師總結之建議。 |
| Short | 醫師總結之建議。 |
| Control | 0..1 |
| Type | Annotation |
| 54. IMAGE.verificationTime | |
| Definition | 確認報告時間(分)，格式為西元YYYYMMDDHHMM。 |
| Short | 確認報告時間(分)，格式為西元YYYYMMDDHHMM。 |
| Control | 1..1 |
| Type | dateTime |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 56. IMAGE.verificationPhysician | |
| Definition | 報告醫師姓名 |
| Short | 報告醫師姓名 |
| Control | 1..1 |
| Type | Practitioner |
Guidance on how to interpret the contents of this table can be found here
| 0. IMAGE | |
| Definition | Medical Imaging And Report Base definition for all elements in a resource. |
| Short | 此邏輯模型適用於醫學影像報告Base for all elements |
| Control | 0..* This element is affected by the following invariants: ele-1 |
| Is Modifier | false |
| Logical Model | Instances of this logical model are not marked to be the target of a Reference |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 2. IMAGE.hospitaltype | |
| Definition | 醫院別 |
| Short | 醫院別 |
| Control | 1..1 |
| Type | Base |
| 4. IMAGE.hospitaltype.id | |
| Definition | 醫事機構代碼，院所代碼需與健保申報相同 |
| Short | 醫事機構代碼，院所代碼需與健保申報相同 |
| Control | 1..1 |
| Type | Identifier |
| 6. IMAGE.hospitaltype.name | |
| Definition | 醫事機構名稱，院所名稱需與健保申報相同 |
| Short | 醫事機構名稱，院所名稱需與健保申報相同 |
| Control | 1..1 |
| Type | string |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 8. IMAGE.order | |
| Definition | 檢查項目 |
| Short | 檢查項目 |
| Control | 1..1 |
| Type | Base |
| 10. IMAGE.order.code | |
| Definition | 醫令代碼，檢查健保醫令代碼，需與健保申報相同。 |
| Short | 醫令代碼，檢查健保醫令代碼，需與健保申報相同。 |
| Control | 1..1 |
| Type | CodeableConcept |
| 12. IMAGE.order.description | |
| Definition | 醫令名稱，檢查健保醫令名稱，需與健保申報相同。 |
| Short | 醫令名稱，檢查健保醫令名稱，需與健保申報相同。 |
| Control | 1..1 |
| Type | string |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 14. IMAGE.examinationStatus | |
| Definition | 檢查部位 |
| Short | 檢查部位 |
| Control | 1..1 |
| Type | Base |
| 16. IMAGE.examinationStatus.physicalExamination | |
| Definition | 檢查部位，檢查部位，需與健保申報相同。 |
| Short | 檢查部位，檢查部位，需與健保申報相同。 |
| Control | 1..* |
| Type | Coding |
| 18. IMAGE.examinationStatus.description | |
| Definition | 檢查部位詳細說明、拍攝方向與角度等 |
| Short | 檢查部位詳細說明、拍攝方向與角度等 |
| Control | 0..1 |
| Type | string |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 20. IMAGE.numberOfInstances | |
| Definition | 檢查張數 |
| Short | 檢查張數 |
| Control | 1..* |
| Type | unsignedInt |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 22. IMAGE.accessionNo | |
| Definition | 檢查單號，須與影像資料串連，每筆檢查必須有獨立不重複的單號。 |
| Short | 檢查單號，須與影像資料串連，每筆檢查必須有獨立不重複的單號。 |
| Control | 1..1 |
| Type | Identifier |
| 24. IMAGE.patientInformation | |
| Definition | 病人基本資料 |
| Short | 病人基本資料 |
| Control | 1..1 |
| Type | Base |
| 26. IMAGE.patientInformation.idNumber | |
| Definition | 身分證號，病人身分證號。 |
| Short | 身分證號，病人身分證號。 |
| Control | 1..1 |
| Type | Identifier |
| 28. IMAGE.patientInformation.chartNO | |
| Definition | 病歷號碼，院內病歷號碼。 |
| Short | 病歷號碼，院內病歷號碼。 |
| Control | 1..1 |
| Type | Identifier |
| 30. IMAGE.patientInformation.name | |
| Definition | 姓名 |
| Short | 姓名 |
| Control | 1..1 |
| Type | string |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 32. IMAGE.patientInformation.administrativeSex | |
| Definition | 性別 |
| Short | 性別 |
| Control | 1..1 |
| Type | code |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 34. IMAGE.patientInformation.birthDate | |
| Definition | 出生日期 |
| Short | 出生日期 |
| Control | 1..1 |
| Type | date |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 36. IMAGE.medicalOrder | |
| Definition | 醫囑時間及醫囑醫師資料 |
| Short | 醫囑時間及醫囑醫師資料 |
| Control | 1..1 |
| Type | Base |
| 38. IMAGE.medicalOrder.orderDatetime | |
| Definition | 醫囑時間，醫囑日期（分），格式為西元YYYYMMDDHHMM。 |
| Short | 醫囑時間，醫囑日期（分），格式為西元YYYYMMDDHHMM。 |
| Control | 1..1 |
| Type | Period |
| 40. IMAGE.medicalOrder.orderPhysician | |
| Definition | 醫囑醫師姓名 |
| Short | 醫囑醫師姓名 |
| Control | 1..1 |
| Type | Practitioner |
| 42. IMAGE.historyOfPresentIllness | |
| Definition | 病史，病人病史，內容可以包含主訴、適應症等。 |
| Short | 病史，病人病史，內容可以包含主訴、適應症等。 |
| Control | 1..* |
| Type | CodeableConcept |
| 44. IMAGE.diagnosisICDcode | |
| Definition | 疾病診斷，疾病診斷代碼及文字。 |
| Short | 疾病診斷，疾病診斷代碼及文字。 |
| Control | 0..* |
| Type | CodeableConcept |
| 46. IMAGE.examDatetime | |
| Definition | 實際檢查日期時間(分) ，格式為西元YYYYMMDDHHMM。 |
| Short | 實際檢查日期時間(分) ，格式為西元YYYYMMDDHHMM。 |
| Control | 1..1 |
| Type | dateTime |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 48. IMAGE.picture | |
| Definition | 圖片 |
| Short | 圖片 |
| Control | 1..* |
| Type | ImagingStudy |
| 50. IMAGE.recordTotal | |
| Definition | 報告結果，含影像發現、臆斷及註記(如過敏反應、顯影劑種類等)。 |
| Short | 報告結果，含影像發現、臆斷及註記(如過敏反應、顯影劑種類等)。 |
| Control | 1..* |
| Type | string |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 52. IMAGE.radiologyStudyRecommendation | |
| Definition | 醫師總結之建議。 |
| Short | 醫師總結之建議。 |
| Control | 0..1 |
| Type | Annotation |
| 54. IMAGE.verificationTime | |
| Definition | 確認報告時間(分)，格式為西元YYYYMMDDHHMM。 |
| Short | 確認報告時間(分)，格式為西元YYYYMMDDHHMM。 |
| Control | 1..1 |
| Type | dateTime |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 56. IMAGE.verificationPhysician | |
| Definition | 報告醫師姓名 |
| Short | 報告醫師姓名 |
| Control | 1..1 |
| Type | Practitioner |
Guidance on how to interpret the contents of this table can be found here
| 0. IMAGE | |
| Definition | Medical Imaging And Report |
| Short | 此邏輯模型適用於醫學影像報告 |
| Control | 0..* This element is affected by the following invariants: ele-1 |
| Is Modifier | false |
| Logical Model | Instances of this logical model are not marked to be the target of a Reference |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 2. IMAGE.id | |
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
| Short | Unique id for inter-element referencing |
| Control | 0..1 |
| Type | string |
| Is Modifier | false |
| XML Format | In the XML format, this property is represented as an attribute. |
| Summary | false |
| 4. IMAGE.extension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
| Short | Additional content defined by implementations |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | false |
| Summary | false |
| Alternate Names | extensions, user content |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) |
| Slicing | This element introduces a set of slices on IMAGE.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 6. IMAGE.hospitaltype | |
| Definition | 醫院別 |
| Short | 醫院別 |
| Control | 1..1 |
| Type | Base |
| 8. IMAGE.hospitaltype.id | |
| Definition | 醫事機構代碼，院所代碼需與健保申報相同 |
| Short | 醫事機構代碼，院所代碼需與健保申報相同 |
| Control | 1..1 |
| Type | Identifier |
| 10. IMAGE.hospitaltype.name | |
| Definition | 醫事機構名稱，院所名稱需與健保申報相同 |
| Short | 醫事機構名稱，院所名稱需與健保申報相同 |
| Control | 1..1 |
| Type | string |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 12. IMAGE.order | |
| Definition | 檢查項目 |
| Short | 檢查項目 |
| Control | 1..1 |
| Type | Base |
| 14. IMAGE.order.code | |
| Definition | 醫令代碼，檢查健保醫令代碼，需與健保申報相同。 |
| Short | 醫令代碼，檢查健保醫令代碼，需與健保申報相同。 |
| Control | 1..1 |
| Type | CodeableConcept |
| 16. IMAGE.order.description | |
| Definition | 醫令名稱，檢查健保醫令名稱，需與健保申報相同。 |
| Short | 醫令名稱，檢查健保醫令名稱，需與健保申報相同。 |
| Control | 1..1 |
| Type | string |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 18. IMAGE.examinationStatus | |
| Definition | 檢查部位 |
| Short | 檢查部位 |
| Control | 1..1 |
| Type | Base |
| 20. IMAGE.examinationStatus.physicalExamination | |
| Definition | 檢查部位，檢查部位，需與健保申報相同。 |
| Short | 檢查部位，檢查部位，需與健保申報相同。 |
| Control | 1..* |
| Type | Coding |
| 22. IMAGE.examinationStatus.description | |
| Definition | 檢查部位詳細說明、拍攝方向與角度等 |
| Short | 檢查部位詳細說明、拍攝方向與角度等 |
| Control | 0..1 |
| Type | string |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 24. IMAGE.numberOfInstances | |
| Definition | 檢查張數 |
| Short | 檢查張數 |
| Control | 1..* |
| Type | unsignedInt |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 26. IMAGE.accessionNo | |
| Definition | 檢查單號，須與影像資料串連，每筆檢查必須有獨立不重複的單號。 |
| Short | 檢查單號，須與影像資料串連，每筆檢查必須有獨立不重複的單號。 |
| Control | 1..1 |
| Type | Identifier |
| 28. IMAGE.patientInformation | |
| Definition | 病人基本資料 |
| Short | 病人基本資料 |
| Control | 1..1 |
| Type | Base |
| 30. IMAGE.patientInformation.idNumber | |
| Definition | 身分證號，病人身分證號。 |
| Short | 身分證號，病人身分證號。 |
| Control | 1..1 |
| Type | Identifier |
| 32. IMAGE.patientInformation.chartNO | |
| Definition | 病歷號碼，院內病歷號碼。 |
| Short | 病歷號碼，院內病歷號碼。 |
| Control | 1..1 |
| Type | Identifier |
| 34. IMAGE.patientInformation.name | |
| Definition | 姓名 |
| Short | 姓名 |
| Control | 1..1 |
| Type | string |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 36. IMAGE.patientInformation.administrativeSex | |
| Definition | 性別 |
| Short | 性別 |
| Control | 1..1 |
| Type | code |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 38. IMAGE.patientInformation.birthDate | |
| Definition | 出生日期 |
| Short | 出生日期 |
| Control | 1..1 |
| Type | date |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 40. IMAGE.medicalOrder | |
| Definition | 醫囑時間及醫囑醫師資料 |
| Short | 醫囑時間及醫囑醫師資料 |
| Control | 1..1 |
| Type | Base |
| 42. IMAGE.medicalOrder.orderDatetime | |
| Definition | 醫囑時間，醫囑日期（分），格式為西元YYYYMMDDHHMM。 |
| Short | 醫囑時間，醫囑日期（分），格式為西元YYYYMMDDHHMM。 |
| Control | 1..1 |
| Type | Period |
| 44. IMAGE.medicalOrder.orderPhysician | |
| Definition | 醫囑醫師姓名 |
| Short | 醫囑醫師姓名 |
| Control | 1..1 |
| Type | Practitioner |
| 46. IMAGE.historyOfPresentIllness | |
| Definition | 病史，病人病史，內容可以包含主訴、適應症等。 |
| Short | 病史，病人病史，內容可以包含主訴、適應症等。 |
| Control | 1..* |
| Type | CodeableConcept |
| 48. IMAGE.diagnosisICDcode | |
| Definition | 疾病診斷，疾病診斷代碼及文字。 |
| Short | 疾病診斷，疾病診斷代碼及文字。 |
| Control | 0..* |
| Type | CodeableConcept |
| 50. IMAGE.examDatetime | |
| Definition | 實際檢查日期時間(分) ，格式為西元YYYYMMDDHHMM。 |
| Short | 實際檢查日期時間(分) ，格式為西元YYYYMMDDHHMM。 |
| Control | 1..1 |
| Type | dateTime |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 52. IMAGE.picture | |
| Definition | 圖片 |
| Short | 圖片 |
| Control | 1..* |
| Type | ImagingStudy |
| 54. IMAGE.recordTotal | |
| Definition | 報告結果，含影像發現、臆斷及註記(如過敏反應、顯影劑種類等)。 |
| Short | 報告結果，含影像發現、臆斷及註記(如過敏反應、顯影劑種類等)。 |
| Control | 1..* |
| Type | string |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 56. IMAGE.radiologyStudyRecommendation | |
| Definition | 醫師總結之建議。 |
| Short | 醫師總結之建議。 |
| Control | 0..1 |
| Type | Annotation |
| 58. IMAGE.verificationTime | |
| Definition | 確認報告時間(分)，格式為西元YYYYMMDDHHMM。 |
| Short | 確認報告時間(分)，格式為西元YYYYMMDDHHMM。 |
| Control | 1..1 |
| Type | dateTime |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 60. IMAGE.verificationPhysician | |
| Definition | 報告醫師姓名 |
| Short | 報告醫師姓名 |
| Control | 1..1 |
| Type | Practitioner |