電子病歷交換單張實作指引(EMR-IG)
0.2.0 - ci-build
This page is part of the 電子病歷交換單張實作指引(EMR-IG) (v0.2.0: Releases) 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
| Official URL: https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRClinicalImpressionObjective | Version: 0.2.0 | |||
| Active as of 2025-01-20 | Computable Name: PMRClinicalImpressionObjective | |||
此Profile用於描述門診病歷中病情摘要之客觀描述_Objective [FMM1]
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
![]() |
0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management | |
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children |
![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
![]() ![]() |
?!SΣ | 1..1 | code | in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. ele-1: All FHIR elements must have a @value or children Fixed Value: completed |
![]() ![]() |
SΣ | 1..1 | CodeableConcept | Kind of assessment performed Binding Description (No ValueSet): (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed. ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() |
SΣ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:code ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() |
SΣ | 1..* | Coding | Code defined by a terminology system ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | uri | Identity of the terminology system ele-1: All FHIR elements must have a @value or children Fixed Value: http://loinc.org |
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | code | Symbol in syntax defined by the system ele-1: All FHIR elements must have a @value or children Fixed Value: 61149-1 |
![]() ![]() ![]() ![]() ![]() |
SΣ | 0..1 | string | Representation defined by the system ele-1: All FHIR elements must have a @value or children Fixed Value: Objective Narrative |
![]() ![]() ![]() |
SΣ | 0..1 | string | 概念的文字表示法 ele-1: All FHIR elements must have a @value or children |
![]() ![]() |
SΣ | 1..1 | Reference(門診病歷-病人基本資料) | Patient or group assessed ele-1: All FHIR elements must have a @value or children |
![]() ![]() |
S | 1..* | Annotation | Comments made about the ClinicalImpression ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() |
SΣ | 1..1 | markdown | 關於此ClinicalImpression的附加資訊。[應填入於門診病歷客觀描述Objective] ele-1: All FHIR elements must have a @value or children |
Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| ClinicalImpression.status | required | Fixed Value: completedhttp://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1from the FHIR Standard | |
| ClinicalImpression.code | example |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | ClinicalImpression | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | ClinicalImpression | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | ClinicalImpression | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | ClinicalImpression | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | ClinicalImpression | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from ClinicalImpression
| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
![]() |
0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
![]() ![]() |
S | 1..1 | code | in-progress | completed | entered-in-error Fixed Value: completed |
![]() ![]() |
S | 1..1 | CodeableConcept | Kind of assessment performed |
![]() ![]() ![]() |
S | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:code |
![]() ![]() ![]() ![]() |
S | 1..* | Coding | Code defined by a terminology system |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61149-1 |
![]() ![]() ![]() ![]() ![]() |
S | 0..1 | string | Representation defined by the system Fixed Value: Objective Narrative |
![]() ![]() ![]() |
S | 0..1 | string | 概念的文字表示法 |
![]() ![]() |
S | 1..1 | Reference(門診病歷-病人基本資料) | Patient or group assessed |
![]() ![]() |
S | 1..* | Annotation | Comments made about the ClinicalImpression |
![]() ![]() ![]() |
S | 1..1 | markdown | 關於此ClinicalImpression的附加資訊。[應填入於門診病歷客觀描述Objective] |
Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints![]() | ||||
|---|---|---|---|---|---|---|---|---|
![]() |
0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |||||
![]() ![]() |
Σ | 0..1 | id | Logical id of this artifact | ||||
![]() ![]() |
Σ | 0..1 | Meta | Metadata about the resource | ||||
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
![]() ![]() |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
![]() ![]() |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
![]() ![]() |
0..* | Resource | Contained, inline Resources | |||||
![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
![]() ![]() |
Σ | 0..* | Identifier | Business identifier | ||||
![]() ![]() |
?!SΣ | 1..1 | code | in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. Fixed Value: completed | ||||
![]() ![]() |
0..1 | CodeableConcept | Reason for current status Binding Description (No ValueSet): (example): Codes identifying the reason for the current state of a clinical impression. | |||||
![]() ![]() |
SΣ | 1..1 | CodeableConcept | Kind of assessment performed Binding Description (No ValueSet): (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed. | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() |
SΣ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:code | ||||
![]() ![]() ![]() ![]() |
SΣ | 1..* | Coding | Code defined by a terminology system | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Version of the system - if relevant | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61149-1 | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 0..1 | string | Representation defined by the system Fixed Value: Objective Narrative | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
![]() ![]() ![]() |
SΣ | 0..1 | string | 概念的文字表示法 | ||||
![]() ![]() |
Σ | 0..1 | string | Why/how the assessment was performed | ||||
![]() ![]() |
SΣ | 1..1 | Reference(門診病歷-病人基本資料) | Patient or group assessed | ||||
![]() ![]() |
Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
![]() ![]() |
Σ | 0..1 | Time of assessment | |||||
![]() ![]() ![]() |
dateTime | |||||||
![]() ![]() ![]() |
Period | |||||||
![]() ![]() |
Σ | 0..1 | dateTime | When the assessment was documented | ||||
![]() ![]() |
Σ | 0..1 | Reference(Practitioner | PractitionerRole) | The clinician performing the assessment | ||||
![]() ![]() |
0..1 | Reference(ClinicalImpression) | Reference to last assessment | |||||
![]() ![]() |
Σ | 0..* | Reference(Condition | AllergyIntolerance) | Relevant impressions of patient state | ||||
![]() ![]() |
0..* | BackboneElement | One or more sets of investigations (signs, symptoms, etc.) | |||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() |
1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. | |||||
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0..* | Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media) | Record of a specific investigation | |||||
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0..* | uri | Clinical Protocol followed | |||||
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0..1 | string | Summary of the assessment | |||||
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0..* | BackboneElement | Possible or likely findings and diagnoses | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() |
0..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |||||
![]() ![]() ![]() |
0..1 | Reference(Condition | Observation | Media) | What was found | |||||
![]() ![]() ![]() |
0..1 | string | Which investigations support finding | |||||
![]() ![]() |
0..* | CodeableConcept | Estimate of likely outcome Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings. | |||||
![]() ![]() |
0..* | Reference(RiskAssessment) | RiskAssessment expressing likely outcome | |||||
![]() ![]() |
0..* | Reference(Resource) | Information supporting the clinical impression | |||||
![]() ![]() |
S | 1..* | Annotation | Comments made about the ClinicalImpression | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() |
Σ | 0..1 | Individual responsible for the annotation | |||||
![]() ![]() ![]() ![]() |
Reference(Practitioner | Patient | RelatedPerson | Organization) | |||||||
![]() ![]() ![]() ![]() |
string | |||||||
![]() ![]() ![]() |
Σ | 0..1 | dateTime | When the annotation was made | ||||
![]() ![]() ![]() |
SΣ | 1..1 | markdown | 關於此ClinicalImpression的附加資訊。[應填入於門診病歷客觀描述Objective] | ||||
Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| ClinicalImpression.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard
| ||||
| ClinicalImpression.status | required | Fixed Value: completedhttp://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1from the FHIR Standard | ||||
| ClinicalImpression.statusReason | example | |||||
| ClinicalImpression.code | example | |||||
| ClinicalImpression.investigation.code | example | InvestigationTypehttp://hl7.org/fhir/ValueSet/investigation-setsfrom the FHIR Standard | ||||
| ClinicalImpression.finding.itemCodeableConcept | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-codefrom the FHIR Standard | ||||
| ClinicalImpression.prognosisCodeableConcept | example | ClinicalImpressionPrognosishttp://hl7.org/fhir/ValueSet/clinicalimpression-prognosisfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | ClinicalImpression | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | ClinicalImpression | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | ClinicalImpression | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | ClinicalImpression | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | ClinicalImpression | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from ClinicalImpression
Summary
Mandatory: 6 elements
Must-Support: 11 elements
Fixed: 4 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
![]() |
0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management | |
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children |
![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
![]() ![]() |
?!SΣ | 1..1 | code | in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. ele-1: All FHIR elements must have a @value or children Fixed Value: completed |
![]() ![]() |
SΣ | 1..1 | CodeableConcept | Kind of assessment performed Binding Description (No ValueSet): (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed. ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() |
SΣ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:code ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() |
SΣ | 1..* | Coding | Code defined by a terminology system ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | uri | Identity of the terminology system ele-1: All FHIR elements must have a @value or children Fixed Value: http://loinc.org |
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | code | Symbol in syntax defined by the system ele-1: All FHIR elements must have a @value or children Fixed Value: 61149-1 |
![]() ![]() ![]() ![]() ![]() |
SΣ | 0..1 | string | Representation defined by the system ele-1: All FHIR elements must have a @value or children Fixed Value: Objective Narrative |
![]() ![]() ![]() |
SΣ | 0..1 | string | 概念的文字表示法 ele-1: All FHIR elements must have a @value or children |
![]() ![]() |
SΣ | 1..1 | Reference(門診病歷-病人基本資料) | Patient or group assessed ele-1: All FHIR elements must have a @value or children |
![]() ![]() |
S | 1..* | Annotation | Comments made about the ClinicalImpression ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() |
SΣ | 1..1 | markdown | 關於此ClinicalImpression的附加資訊。[應填入於門診病歷客觀描述Objective] ele-1: All FHIR elements must have a @value or children |
Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| ClinicalImpression.status | required | Fixed Value: completedhttp://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1from the FHIR Standard | |
| ClinicalImpression.code | example |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | ClinicalImpression | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | ClinicalImpression | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | ClinicalImpression | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | ClinicalImpression | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | ClinicalImpression | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Differential View
This structure is derived from ClinicalImpression
| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
![]() |
0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
![]() ![]() |
S | 1..1 | code | in-progress | completed | entered-in-error Fixed Value: completed |
![]() ![]() |
S | 1..1 | CodeableConcept | Kind of assessment performed |
![]() ![]() ![]() |
S | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:code |
![]() ![]() ![]() ![]() |
S | 1..* | Coding | Code defined by a terminology system |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61149-1 |
![]() ![]() ![]() ![]() ![]() |
S | 0..1 | string | Representation defined by the system Fixed Value: Objective Narrative |
![]() ![]() ![]() |
S | 0..1 | string | 概念的文字表示法 |
![]() ![]() |
S | 1..1 | Reference(門診病歷-病人基本資料) | Patient or group assessed |
![]() ![]() |
S | 1..* | Annotation | Comments made about the ClinicalImpression |
![]() ![]() ![]() |
S | 1..1 | markdown | 關於此ClinicalImpression的附加資訊。[應填入於門診病歷客觀描述Objective] |
Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints![]() | ||||
|---|---|---|---|---|---|---|---|---|
![]() |
0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |||||
![]() ![]() |
Σ | 0..1 | id | Logical id of this artifact | ||||
![]() ![]() |
Σ | 0..1 | Meta | Metadata about the resource | ||||
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
![]() ![]() |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
![]() ![]() |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
![]() ![]() |
0..* | Resource | Contained, inline Resources | |||||
![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
![]() ![]() |
Σ | 0..* | Identifier | Business identifier | ||||
![]() ![]() |
?!SΣ | 1..1 | code | in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. Fixed Value: completed | ||||
![]() ![]() |
0..1 | CodeableConcept | Reason for current status Binding Description (No ValueSet): (example): Codes identifying the reason for the current state of a clinical impression. | |||||
![]() ![]() |
SΣ | 1..1 | CodeableConcept | Kind of assessment performed Binding Description (No ValueSet): (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed. | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() |
SΣ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:code | ||||
![]() ![]() ![]() ![]() |
SΣ | 1..* | Coding | Code defined by a terminology system | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Version of the system - if relevant | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61149-1 | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 0..1 | string | Representation defined by the system Fixed Value: Objective Narrative | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
![]() ![]() ![]() |
SΣ | 0..1 | string | 概念的文字表示法 | ||||
![]() ![]() |
Σ | 0..1 | string | Why/how the assessment was performed | ||||
![]() ![]() |
SΣ | 1..1 | Reference(門診病歷-病人基本資料) | Patient or group assessed | ||||
![]() ![]() |
Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
![]() ![]() |
Σ | 0..1 | Time of assessment | |||||
![]() ![]() ![]() |
dateTime | |||||||
![]() ![]() ![]() |
Period | |||||||
![]() ![]() |
Σ | 0..1 | dateTime | When the assessment was documented | ||||
![]() ![]() |
Σ | 0..1 | Reference(Practitioner | PractitionerRole) | The clinician performing the assessment | ||||
![]() ![]() |
0..1 | Reference(ClinicalImpression) | Reference to last assessment | |||||
![]() ![]() |
Σ | 0..* | Reference(Condition | AllergyIntolerance) | Relevant impressions of patient state | ||||
![]() ![]() |
0..* | BackboneElement | One or more sets of investigations (signs, symptoms, etc.) | |||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. | |||||
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0..* | Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media) | Record of a specific investigation | |||||
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0..* | uri | Clinical Protocol followed | |||||
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0..1 | string | Summary of the assessment | |||||
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0..* | BackboneElement | Possible or likely findings and diagnoses | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |||||
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0..1 | Reference(Condition | Observation | Media) | What was found | |||||
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0..1 | string | Which investigations support finding | |||||
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0..* | CodeableConcept | Estimate of likely outcome Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings. | |||||
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0..* | Reference(RiskAssessment) | RiskAssessment expressing likely outcome | |||||
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0..* | Reference(Resource) | Information supporting the clinical impression | |||||
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S | 1..* | Annotation | Comments made about the ClinicalImpression | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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Σ | 0..1 | Individual responsible for the annotation | |||||
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Reference(Practitioner | Patient | RelatedPerson | Organization) | |||||||
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string | |||||||
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Σ | 0..1 | dateTime | When the annotation was made | ||||
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SΣ | 1..1 | markdown | 關於此ClinicalImpression的附加資訊。[應填入於門診病歷客觀描述Objective] | ||||
Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| ClinicalImpression.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard
| ||||
| ClinicalImpression.status | required | Fixed Value: completedhttp://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1from the FHIR Standard | ||||
| ClinicalImpression.statusReason | example | |||||
| ClinicalImpression.code | example | |||||
| ClinicalImpression.investigation.code | example | InvestigationTypehttp://hl7.org/fhir/ValueSet/investigation-setsfrom the FHIR Standard | ||||
| ClinicalImpression.finding.itemCodeableConcept | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-codefrom the FHIR Standard | ||||
| ClinicalImpression.prognosisCodeableConcept | example | ClinicalImpressionPrognosishttp://hl7.org/fhir/ValueSet/clinicalimpression-prognosisfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | ClinicalImpression | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | ClinicalImpression | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | ClinicalImpression | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | ClinicalImpression | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | ClinicalImpression | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from ClinicalImpression
Summary
Mandatory: 6 elements
Must-Support: 11 elements
Fixed: 4 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron