臺灣核心實作指引(TW Core IG)
0.1.1 - Trial Use

This page is part of the 臺灣核心實作指引(TW Core IG) (v0.1.1: Releases) based on FHIR 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

Resource Profile: TWCoreProcedure - Detailed Descriptions

Active as of 2023-08-30

Definitions for the Procedure-twcore resource profile.

Guidance on how to interpret the contents of this table can be found here

0. Procedure
Definition

正在或曾經對病人執行的動作。這可以是像手術這樣的身體介入,也可以是像長照服務、諮詢或催眠療法這樣的非侵入性介入。HL7 FHIR官網另有提到的例子包括例如包括診斷處置、內視鏡處置、活體組織切片、諮詢、物理治療、個人支持服務、日照服務、非緊急運輸、改善家居設施、健身活動等。處置可以由醫護人員、服務提供人員、朋友或親屬或在某些情況下由病人自己執行。

Short正在或曾經對病人執行的動作
2. Procedure.id
Definition

resource的邏輯ID,在resource的URL中使用。一旦指定,這個值永遠不會改變。

Short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。
Comments

一個resource使用新增操作(create operation)提交給伺服器時是此resource唯一沒有id的時刻

4. Procedure.meta
Definition

關於resource的metadata。這是由基礎建設維護的內容。對內容的改變可能並不總是與resource的版本改變相關。

Short此Procedure Resource的metadata
6. Procedure.implicitRules
Definition

構建resource時遵循的一系列規則的參照,在處理內容時必須理解這些規則。通常這是IG定義特殊規則及其他profiles的參照。

Short創建此內容所依據的一組規則
Comments

宣告這套規則限制了內容只能被有限的貿易夥伴所理解。這從本質上限制了資料的長期有用性。然而,現有的健康生態體系高度分裂,還沒有準備好以普遍可計算的方式定義、收集和交換資料。只要有可能,實作者和/或規範編寫者應該避免使用這個資料項目。通常,在使用時,此URL是對實作指引的參照,此指引將這些特殊規則與其他profiles、value sets等一起定義為其敘述的一部分。

8. Procedure.language
Definition

編寫此resource的基礎語言

Short用以表述Procedure Resource內容的語言
Comments

提供語言是為了支援索引和可存取性(通常,文字表述轉語音等服務使用此語言標籤)。html lanuage tag適用於此敘述。resource上的語言標籤可用於指定從resource中的資料所產成的其他表述之語言。不是所有的內容都必須使用此基礎語言。不應該假定Resource.language自動適用於敘述。如果指定語言,它也應該被指定在html中的div元素(關於xml:lang和html lang屬性之間的關係,見HTML5中的規則)。

BindingThe codes SHOULD be taken from CommonLanguages: 人類語言;鼓勵使用CommonLanguages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。
Additional BindingsPurpose
AllLanguagesMax Binding
Example<br/><b>Value</b>:zh-TW
10. Procedure.text
Definition

人可讀的敘述,包含resource的摘要,可用於向人表述resource的內容。敘述不需要對所有的結構化資料進行編碼,但需要包含足夠的細節使人在閱讀敘述時理解「臨床安全性」。resource定義可定義哪些內容應該在敘述中表示,以確保臨床安全。

ShortProcedure Resource之內容摘要以供人閱讀
Comments

內嵌(contained)的resource沒有敘述,非內嵌(contained)的resource則 建議應該(SHOULD) 有敘述。在某些情況下,resource可能只有文字表述,很少或沒有額外的離散資料(只要滿足所有minOccurs=1的資料項目)。這對於來自舊有系統的資料可能是必要的,在這些系統中,從 「文字表述區塊(text blob) 」獲取訊息,或者文字表述是額外的原始輸入或敘述,而編碼訊息是後來添加的。

Must Supporttrue
12. Procedure.contained
Definition

這些resource內嵌(contains)的resource不會另外存於任何FHIR伺服器,意即它們無法在任何FHIR伺服器中被找到,也無法有自己獨立的資料異動/交易(transaction)範圍。

Short內嵌的(contained)、行內的Resources
Comments

當內容可以從任何FHIR伺服器找到時,不應該以內嵌(contained)resource的方式呈現,因為一旦識別丟失,要再次恢復它是非常困難的(並且取決於情境)。內嵌(contained)的resource可在它們的meta資料項目中表述profiles和tag(標籤),但 必須沒有(SHALL NOT) 資訊安全標號(security labels)。

14. Procedure.extension
Definition

可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

Short擴充的資料項目
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

16. Procedure.modifierExtension
Definition

可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。 修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。

Short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。
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

Requirements

修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互通性。更多訊息,請參見修飾用的資料項目擴充之定義

18. Procedure.identifier
Definition

由執行者或其他系統指定給此處置的業務用識別碼,即使此resource作更新及在伺服器之間的傳遞,此識別碼仍保持不變。

Short此處置的外部識別碼
Comments

這是一個業務識別碼,不是一個resource識別碼(詳見討論)。最好的做法是該識別碼只出現在單個resource實例上,但是業務實務有可能會規定可以在多個resource實例中具有相同識別碼—甚至可能具有不同的resource型例。例如:多個 「Patient(病人)」和 「Person(個人)」resource實例可能共用同一個社會保險號碼。

NoteThis is a business identifier, not a resource identifier (see discussion)
Requirements

允許識別各參與系統所知的此處置資訊,並在各伺服器之間保持一致的方式。

20. Procedure.instantiatesCanonical
Definition

指向此處置全部或部分遵守的FHIR定義的計畫書(protocol)、指南(guideline)、醫令集(orderset)或其他定義的URL。

Short實例化FHIR計畫書(protocol)或定義
22. Procedure.instantiatesUri
Definition

指向此處置全部或部分的外部維護之計畫書(protocol)、指南(guideline)、醫令集(orderset)或其他定義的URL。

Short實例化外部計畫書(protocol)或定義
Comments

這可能是一個HTML頁面、PDF等,也可能只是一個不可分解的URI識別碼。

24. Procedure.basedOn
Definition

對一個resource的參照,此resource包含此處置請求的細節。

Short此Procedure是基於什麼而履行?
26. Procedure.partOf
Definition

這個特定的處置是一個更大的事件中的一個組成部分或步驟

Short參照事件的一部分
Comments

MedicationAdministration.partOf有一個Procedure參照,但這不是一個迴圈參照。例如:麻醉的給藥(MedicationAdministration)是手術處置的一部分(MedicationAdministration.partOf = Procedure)。例如:為靜脈給藥插入靜脈口的處置是給藥的一部分(Procedure.partOf = MedicationAdministration)。

TypeReference(TW Core Procedure, TW Core Observation Laboratory Result, MedicationAdministration)
28. Procedure.status
Definition

一個指定處置當前狀態的代碼。一般來說,它是進行中或完成的狀態。

Shortpreparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknown
Comments

「未知」代碼不能用來表達其他狀態。當其中一個狀態適用時但編輯系統不知道此處置的當前狀態,應該使用「未知」代碼。

BindingThe codes SHALL be taken from EventStatus: 應填入EventStatus值集中的其中一個代碼
Must Supporttrue
30. Procedure.statusReason
Definition

捕捉Procedure當前狀態的原因

Short當前狀態的原因。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。
Comments

這通常只用於「例外」狀態像是「未完成」、「暫停」或「終止」。執行此處置的原因是在reasonCode中說明,而不是在這裡。

BindingFor example codes, see ProcedureNotPerformedReason(SNOMED-CT): 可參考Procedure Not Performed Reason(SNOMED-CT)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。
TypeCodeableConcept(TW CodeableConcept)
32. Procedure.category
Definition

對處置進行分類的代碼(例如:「手術處置」)。主要為了搜尋、排序和顯示時使用。

Short處置的分類。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。
BindingFor example codes, see ProcedureCategoryCodes(SNOMEDCT): 可參考Procedure Category Codes(SNOMED CT)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。
TypeCodeableConcept(TW CodeableConcept)
34. Procedure.code
Definition

所進行的特定處置。如果不能對處置的確切種類進行編碼,則使用文字(例如:「腹腔鏡闌尾切除術」)。

Short處置的識別碼。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。
Control1..?
BindingFor example codes, see ProcedureCodes(SNOMEDCT): 可參考Procedure Codes(SNOMED CT)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。
TypeCodeableConcept(TW CodeableConcept)
Must Supporttrue
Requirements

0..1主要僅用於解釋敘述性的resource。

36. Procedure.code.id
Definition

resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。

Short唯一可識別ID,以供資料項目間相互參照。
38. Procedure.code.extension
Definition

擴充的資料項目

Short擴充的資料項目
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

40. Procedure.code.coding
Definition

由專門術語系統(terminology system)所定義之代碼的參照。

Short由專門術語系統(terminology system)定義的代碼
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

SlicingThis element introduces a set of slices on Procedure.code.coding. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • pattern @ $this
42. Procedure.code.coding:icd10-pcs-2021
Slice Nameicd10-pcs-2021
Definition

由專門術語系統(terminology system)所定義之代碼的參照。

Short此為臺灣衛生福利部中央健康保險署維護之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。
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Control0..1
BindingThe codes SHALL be taken from 臺灣2021年中文版ICD-10-PCS值集: 病情、問題或診斷的識別;應填入臺灣2021年中文版ICD-10-PCS值集值集中的其中一個代碼。
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

44. Procedure.code.coding:icd10-pcs-2014
Slice Nameicd10-pcs-2014
Definition

由專門術語系統(terminology system)所定義之代碼的參照。

Short此為臺灣衛生福利部中央健康保險署維護之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。
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Control0..1
BindingThe codes SHALL be taken from 臺灣2014年中文版ICD-10-PCS值集: 病情、問題或診斷的識別;應填入臺灣2014年中文版ICD-10-PCS值集值集中的其中一個代碼。
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

46. Procedure.code.coding:icd9-cm-2001
Slice Nameicd9-cm-2001
Control0..1
BindingThe codes SHALL be taken from 臺灣2001年中文版ICD-9-CM值集
Must Supporttrue
48. Procedure.code.coding:medical-service-payment
Slice Namemedical-service-payment
Definition

由專門術語系統(terminology system)所定義之代碼的參照。

Short此為中央健康保險署(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。
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Control0..1
BindingThe codes SHALL be taken from 臺灣藥品使用頻率值集: 病情、問題或診斷的識別;應填入臺灣2014年中文版ICD-10-PCS值集值集中的其中一個代碼。
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

50. Procedure.code.coding:sct-procedures-ips
Slice Namesct-procedures-ips
Definition

由專門術語系統(terminology system)所定義之代碼的參照。

Short此為SNOMED CT處置代碼,若機構已有購買相關授權,亦可使用。
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Control0..1
BindingThe codes SHALL be taken from Procedures (SNOMED CT) - IPS: 病情、問題或診斷的識別;應填入Procedures - IPS值集中的其中一個代碼。
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

52. Procedure.code.text
Definition

輸入資料的使用者所見/所選/所說的人類可讀文字表述,和(或)其代表使用者的預期含義。

Short概念的文字表示法
Comments

很多時候,此文字表述與其中一個代碼的顯示名稱相同。

Must Supporttrue
Requirements

專門術語中的代碼並不總是能捕捉人類使用的細微差別的正確意義,或者根本就沒有合適的代碼;這些情況下,文字表述被用來捕捉來源的全部意義。

54. Procedure.subject
Definition

進行處置的病人、動物或實體集合(例如:特定的一群人)。

Short處置服務的對象
TypeReference(TW Core Patient)
Must Supporttrue
56. Procedure.encounter
Definition

此「處置(Procedure)」記載在哪次的「就醫(Encounter)」紀錄或者與此處置紀錄密切相關的「就醫(Encounter)」紀錄

Short就醫(Encounter)紀錄作為處置的一部分
Comments

通常是此處置發生的就醫事件(Encounter),雖然有些活動可能在就醫結束之前或之後開始,但仍與就醫事件的情境有關。這筆紀錄表明與此處置紀錄相關的就醫事件。

TypeReference(TW Core Encounter)
58. Procedure.performed[x]
Definition

進行處置的估計或實際日期、日期時間、時間區間或年齡。允許一個時間區間來支持跨越一個日期以上的複雜處置,也允許捕捉處置的執行時間長度。

Short此處置何時執行的?
Comments

年齡一般用於病人報告其進行手術的年齡,像是20到25歲時。 dateTime支援一定的精度範圍,因為有些處置被報告為過去的處置,可能沒有毫秒的精度,而其他在就醫期間執行和記錄的處置可能有更精確的UTC時間戳記和時區。

TypeChoice of: dateTime, Period, string, Age, Range
[x] NoteSee Choice of Data Types for further information about how to use [x]
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Must Support TypesdateTime
60. Procedure.recorder
Definition

記錄處置內容並對其內容負責的個人

Short誰記錄此處置
TypeReference(TW Core Patient, TW Core Practitioner, PractitionerRole, RelatedPerson)
62. Procedure.asserter
Definition

提出此處置說明的人

Short聲稱有此處置的人
TypeReference(TW Core Patient, RelatedPerson, TW Core Practitioner, PractitionerRole)
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
64. Procedure.performer
Definition

限於「真正的」人而不是設備

Short執行處置的人員
Must Supporttrue
66. Procedure.performer.id
Definition

resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。

Short唯一可識別ID,以供資料項目間相互參照。
68. Procedure.performer.extension
Definition

可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

Short擴充的資料項目
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

70. Procedure.performer.modifierExtension
Definition

可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。 修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。

Short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。
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

Requirements

修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互通性。更多訊息,請參見修飾用的資料項目擴充之定義

72. Procedure.performer.function
Definition

區分執行者在處置中的參與型別,例如:外科醫生、麻醉師、內視鏡醫生。

Short執行的型別
BindingFor example codes, see ProcedurePerformerRoleCodes: 可參考Procedure Performer Role Codes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。
TypeCodeableConcept(TW CodeableConcept)
Requirements

允許針對不同執行者的參與型別進行澄清以消除歧義

74. Procedure.performer.actor
Definition

參與處置的健康照護服務提供人員

Short參照至健康照護服務提供人員
TypeReference(TW Core Practitioner, PractitionerRole, TW Core Organization Hospital Department, TW Core Patient, RelatedPerson, Device)
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Requirements

一個參照至裝置(Device)的使用案例,例如:心律調整器。

76. Procedure.performer.onBehalfOf
Definition

此裝置或健康照護服務提供人員所代表的機構

Short此裝置(Device)或健康照護服務提供人員所屬機構(Organization)
TypeReference(TW Core Organization Hospital Department)
Must Supporttrue
Requirements

健康照護服務提供人員和裝置可以與多個機構相關聯,此資料項目表明他們在執行行動時代表哪個機構。

78. Procedure.location
Definition

實際發生處置的地點(Location)。例如:新生兒在家裡出生、在餐廳做氣管切開術。

Short處置發生的地點(Location)?
Requirements

將一個處置與可能保存紀錄的地點(Location)聯繫起來

80. Procedure.reasonCode
Definition

進行此處置的原因代碼。這可能是某種型別的編碼,也可能只是文字表述。

Short處置執行原因代碼
Comments

當一個代碼足以描述原因時,使用Procedure.reasonCode。當參照一個resource時,使用Procedure.reasonReference以傳達更多的資訊,如發病日期。Procedure.reasonCode和Procedure.reasonReference不應該是重複的。對於一個單一的原因,Procedure.reasonCode或Procedure.reasonReference都可以被使用。Procedure.reasonCode可以是一個摘要代碼,或者Procedure.reasonReference可以用Condition | Observation | Procedure | DiagnosticReport | DocumentReference來參照一個非常精確的原因定義。如果Procedure.reasonCode和Procedure.reasonReference描述的是處置的不同原因,則兩者都可以使用。

BindingFor example codes, see ProcedureReasonCodes: 可[參考Procedure Reason Codes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。
TypeCodeableConcept(TW CodeableConcept)
82. Procedure.reasonReference
Definition

為什麼進行此處置的原因

Short執行此處置的原因
Comments

一個處置有可能成為另一個處置(如C-Section)的理由(如硬膜外)。其他的例子包括擴張的內窺鏡檢查和活檢(診斷和治療的結合)。 當一個代碼充分地描述了原因時,使用Procedure.reasonCode。當引用一個resource時,使用Procedure.reasonReference,這樣可以傳達更多的資訊,如發病日期。Procedure.reasonCode和Procedure.reasonReference不應該是重複的。對於一個單一的原因,Procedure.reasonCode或Procedure.reasonReference都可以被使用。Procedure.reasonCode可以是一個摘要代碼,或者Procedure.reasonReference可以用Condition | Observation | Procedure | DiagnosticReport | DocumentReference來引用一個非常精確的原因定義。如果Procedure.reasonCode和Procedure.reasonReference描述的是處置的不同原因,則兩者都可以使用。

TypeReference(TW Core Condition, TW Core Observation Laboratory Result, TW Core Procedure, DiagnosticReport, DocumentReference)
84. Procedure.bodySite
Definition

詳細和結構化的解剖學位置資訊。允許多個位置—例如:一個病灶的多個活體組織切片。

Short目標身體部位。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。
Comments

如果案例需要BodySite resource的屬性(例如:識別和各別追蹤),那麼就使用標準擴充[procedure-targetbodystructure](擴充-procedure-targetbodystructure.html)。

BindingFor example codes, see SNOMEDCTBodyStructures: 可參考SNOMED CT Body Structures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。
TypeCodeableConcept(TW CodeableConcept)
Must Supporttrue
86. Procedure.outcome
Definition

處置的結果—它是否解決了當初執行處置所要解決的問題?

Short處置的結果。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。
Comments

如果結果只包含敘述性文字,可用CodeableConcept.text來說明。

BindingFor example codes, see ProcedureOutcomeCodes(SNOMEDCT): 可參考Procedure Outcome Codes(SNOMED CT)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。
TypeCodeableConcept(TW CodeableConcept)
88. Procedure.report
Definition

這可能是組織學結果、病理學報告、手術報告等。

Short此處置產生的任何報告
Comments

有可能會有多份報告—例如:如果這是一個需要進行多次活體組織切片的處置,會產生一些解剖病理報告。

90. Procedure.complication
Definition

在處置過程中,或在處置後不久發生的任何併發症。這些通常與紀錄分開追蹤,紀錄通常描述處置本身,而不是任何 「處置後」的問題。

Short處置後的併發症
Comments

如果併發症僅由敘述性文字表達,可用CodeableConcept.text來說明。

BindingFor example codes, see Condition/Problem/DiagnosisCodes: 可參考Condition/Problem/Diagnosis Codes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。
TypeCodeableConcept(TW CodeableConcept)
92. Procedure.complicationDetail
Definition

在處置過程中或在執行結束後立即發生的任何併發症

Short處置後發生的病情、問題或診斷
TypeReference(TW Core Condition)
Requirements

這是用來記錄作為處置結果的病情、問題或診斷,而不是作為處置原因的病情、問題或診斷。

94. Procedure.followUp
Definition

如果該處置需要特定的後續行動—例如拆除縫線。 後續行動可以表現為一個簡單的說明,也可能是更複雜的,在這種情況下,可以使用CarePlan resource。

Short追蹤說明。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。
BindingFor example codes, see ProcedureFollowUpCodes(SNOMEDCT): 可參考Procedure Follow up Codes(SNOMED CT)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。
TypeCodeableConcept(TW CodeableConcept)
96. Procedure.note
Definition

關於此處置的任何其他註釋和意見

Short關於此處置的附加資訊
98. Procedure.focalDevice
Definition

植入、移除或以其他方式操作的裝置(校準、更換電池、安裝義肢、安裝傷口真空裝置等),是處置的重點部分。

Short處理、植入的或移除的裝置
100. Procedure.focalDevice.id
Definition

resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。

Short唯一可識別ID,以供資料項目間相互參照。
102. Procedure.focalDevice.extension
Definition

可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

Short擴充的資料項目
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

104. Procedure.focalDevice.modifierExtension
Definition

可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。 修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。

Short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。
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

Requirements

修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互通性。更多訊息,請參見修飾用的資料項目擴充之定義

106. Procedure.focalDevice.action
Definition

處置過程中,設備改變的類型。

Short改變裝置的種類
BindingThe codes SHOULD be taken from ProcedureDeviceActionCodes: 鼓勵使用Procedure Device Action Codes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。
TypeCodeableConcept(TW CodeableConcept)
108. Procedure.focalDevice.manipulated
Definition

在處置中被處理(改變)的裝置

Short被改變的裝置
110. Procedure.usedReference
Definition

指明藥品、裝置和作為處置一部分的任何其他物質

Short處置中使用的項目/物品
Comments

對於實際植入或取出的裝置,使用Procedure.device。

Requirements

用於追蹤污染等

112. Procedure.usedCode
Definition

指明作為處置的一部分而使用的編碼項目

Short處置中使用的項目之代碼
Comments

對於實際植入或取出的裝置,使用Procedure.device。

BindingFor example codes, see FHIRDeviceTypes: 可參考FHIR Device Types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。
TypeCodeableConcept(TW CodeableConcept)

Guidance on how to interpret the contents of this table can be found here

0. Procedure
Definition

正在或曾經對病人執行的動作。這可以是像手術這樣的身體介入,也可以是像長照服務、諮詢或催眠療法這樣的非侵入性介入。HL7 FHIR官網另有提到的例子包括例如包括診斷處置、內視鏡處置、活體組織切片、諮詢、物理治療、個人支持服務、日照服務、非緊急運輸、改善家居設施、健身活動等。處置可以由醫護人員、服務提供人員、朋友或親屬或在某些情況下由病人自己執行。


An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy.

Short正在或曾經對病人執行的動作An action that is being or was performed on a patient
Control0..*
Is Modifierfalse
Summaryfalse
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
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 (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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. Procedure.id
Definition

resource的邏輯ID,在resource的URL中使用。一旦指定,這個值永遠不會改變。


The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Short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。Logical id of this artifact
Comments

一個resource使用新增操作(create operation)提交給伺服器時是此resource唯一沒有id的時刻


The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Control0..1
Typeidstring
Is Modifierfalse
Summarytrue
4. Procedure.meta
Definition

關於resource的metadata。這是由基礎建設維護的內容。對內容的改變可能並不總是與resource的版本改變相關。


The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Short此Procedure Resource的metadataMetadata about the resource
Control0..1
TypeMeta
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
6. Procedure.implicitRules
Definition

構建resource時遵循的一系列規則的參照,在處理內容時必須理解這些規則。通常這是IG定義特殊規則及其他profiles的參照。


A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Short創建此內容所依據的一組規則A set of rules under which this content was created
Comments

宣告這套規則限制了內容只能被有限的貿易夥伴所理解。這從本質上限制了資料的長期有用性。然而,現有的健康生態體系高度分裂,還沒有準備好以普遍可計算的方式定義、收集和交換資料。只要有可能,實作者和/或規範編寫者應該避免使用這個資料項目。通常,在使用時,此URL是對實作指引的參照,此指引將這些特殊規則與其他profiles、value sets等一起定義為其敘述的一部分。


Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. Procedure.language
Definition

編寫此resource的基礎語言


The base language in which the resource is written.

Short用以表述Procedure Resource內容的語言Language of the resource content
Comments

提供語言是為了支援索引和可存取性(通常,文字表述轉語音等服務使用此語言標籤)。html lanuage tag適用於此敘述。resource上的語言標籤可用於指定從resource中的資料所產成的其他表述之語言。不是所有的內容都必須使用此基礎語言。不應該假定Resource.language自動適用於敘述。如果指定語言,它也應該被指定在html中的div元素(關於xml:lang和html lang屬性之間的關係,見HTML5中的規則)。


Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Control0..1
BindingThe codes SHOULD be taken from CommonLanguageshttp://hl7.org/fhir/ValueSet/languages

人類語言;鼓勵使用CommonLanguages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。


A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Example<br/><b>Value</b>:zh-TW
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. Procedure.text
Definition

人可讀的敘述,包含resource的摘要,可用於向人表述resource的內容。敘述不需要對所有的結構化資料進行編碼,但需要包含足夠的細節使人在閱讀敘述時理解「臨床安全性」。resource定義可定義哪些內容應該在敘述中表示,以確保臨床安全。


A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

ShortProcedure Resource之內容摘要以供人閱讀Text summary of the resource, for human interpretation
Comments

內嵌(contained)的resource沒有敘述,非內嵌(contained)的resource則 建議應該(SHOULD) 有敘述。在某些情況下,resource可能只有文字表述,很少或沒有額外的離散資料(只要滿足所有minOccurs=1的資料項目)。這對於來自舊有系統的資料可能是必要的,在這些系統中,從 「文字表述區塊(text blob) 」獲取訊息,或者文字表述是額外的原始輸入或敘述,而編碼訊息是後來添加的。


Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Control0..1
TypeNarrative
Is Modifierfalse
Must Supporttrue
Summaryfalse
Alternate Namesnarrative, html, xhtml, display
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. Procedure.contained
Definition

這些resource內嵌(contains)的resource不會另外存於任何FHIR伺服器,意即它們無法在任何FHIR伺服器中被找到,也無法有自己獨立的資料異動/交易(transaction)範圍。


These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Short內嵌的(contained)、行內的ResourcesContained, inline Resources
Comments

當內容可以從任何FHIR伺服器找到時,不應該以內嵌(contained)resource的方式呈現,因為一旦識別丟失,要再次恢復它是非常困難的(並且取決於情境)。內嵌(contained)的resource可在它們的meta資料項目中表述profiles和tag(標籤),但 必須沒有(SHALL NOT) 資訊安全標號(security labels)。


This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Control0..*
TypeResource
Is Modifierfalse
Summaryfalse
Alternate Namesinline resources, anonymous resources, contained resources
14. Procedure.extension
Definition

可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。


May be used to represent additional information that is not part of the basic definition of the resource. 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擴充的資料項目Additional content defined by implementations
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。


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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-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())
16. Procedure.modifierExtension
Definition

可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。 修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。


May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Short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。Extensions that cannot be ignored
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。


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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互通性。更多訊息,請參見修飾用的資料項目擴充之定義


Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Invariantsele-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())
18. Procedure.identifier
Definition

由執行者或其他系統指定給此處置的業務用識別碼,即使此resource作更新及在伺服器之間的傳遞,此識別碼仍保持不變。


Business identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and is propagated from server to server.

Short此處置的外部識別碼External Identifiers for this procedure
Comments

這是一個業務識別碼,不是一個resource識別碼(詳見討論)。最好的做法是該識別碼只出現在單個resource實例上,但是業務實務有可能會規定可以在多個resource實例中具有相同識別碼—甚至可能具有不同的resource型例。例如:多個 「Patient(病人)」和 「Person(個人)」resource實例可能共用同一個社會保險號碼。


This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and Person resource instances might share the same social insurance number.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Is Modifierfalse
Summarytrue
Requirements

允許識別各參與系統所知的此處置資訊,並在各伺服器之間保持一致的方式。


Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. Procedure.instantiatesCanonical
Definition

指向此處置全部或部分遵守的FHIR定義的計畫書(protocol)、指南(guideline)、醫令集(orderset)或其他定義的URL。


The URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.

Short實例化FHIR計畫書(protocol)或定義Instantiates FHIR protocol or definition
Control0..*
Typecanonical(PlanDefinition, ActivityDefinition, Measure, OperationDefinition, Questionnaire)
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. Procedure.instantiatesUri
Definition

指向此處置全部或部分的外部維護之計畫書(protocol)、指南(guideline)、醫令集(orderset)或其他定義的URL。


The URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.

Short實例化外部計畫書(protocol)或定義Instantiates external protocol or definition
Comments

這可能是一個HTML頁面、PDF等,也可能只是一個不可分解的URI識別碼。


This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.

Control0..*
Typeuri
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. Procedure.basedOn
Definition

對一個resource的參照,此resource包含此處置請求的細節。


A reference to a resource that contains details of the request for this procedure.

Short此Procedure是基於什麼而履行?A request for this procedure
Control0..*
TypeReference(CarePlan, ServiceRequest)
Is Modifierfalse
Summarytrue
Alternate Namesfulfills
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. Procedure.partOf
Definition

這個特定的處置是一個更大的事件中的一個組成部分或步驟


A larger event of which this particular procedure is a component or step.

Short參照事件的一部分Part of referenced event
Comments

MedicationAdministration.partOf有一個Procedure參照,但這不是一個迴圈參照。例如:麻醉的給藥(MedicationAdministration)是手術處置的一部分(MedicationAdministration.partOf = Procedure)。例如:為靜脈給藥插入靜脈口的處置是給藥的一部分(Procedure.partOf = MedicationAdministration)。


The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration).

Control0..*
TypeReference(TW Core Procedure, TW Core Observation Laboratory Result, MedicationAdministration, Procedure, Observation)
Is Modifierfalse
Summarytrue
Alternate Namescontainer
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. Procedure.status
Definition

一個指定處置當前狀態的代碼。一般來說,它是進行中或完成的狀態。


A code specifying the state of the procedure. Generally, this will be the in-progress or completed state.

Shortpreparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknownpreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Comments

「未知」代碼不能用來表達其他狀態。當其中一個狀態適用時但編輯系統不知道此處置的當前狀態,應該使用「未知」代碼。

此資料項目被標記為修飾用,因為狀態包含標記resource當前無效的代碼。


The "unknown" code is not to be used to convey other statuses. The "unknown" code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Control1..1
BindingThe codes SHALL be taken from EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1

應填入EventStatus值集中的其中一個代碼


A code specifying the state of the procedure.

Typecode
Is Modifiertrue because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. Procedure.statusReason
Definition

捕捉Procedure當前狀態的原因


Captures the reason for the current state of the procedure.

Short當前狀態的原因。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。Reason for current status
Comments

這通常只用於「例外」狀態像是「未完成」、「暫停」或「終止」。執行此處置的原因是在reasonCode中說明,而不是在這裡。


This is generally only used for "exception" statuses such as "not-done", "suspended" or "aborted". The reason for performing the event at all is captured in reasonCode, not here.

Control0..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reason

可參考Procedure Not Performed Reason(SNOMED-CT)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。


A code that identifies the reason a procedure was not performed.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Alternate NamesSuspended Reason, Cancelled Reason
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. Procedure.category
Definition

對處置進行分類的代碼(例如:「手術處置」)。主要為了搜尋、排序和顯示時使用。


A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure").

Short處置的分類。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。Classification of the procedure
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control0..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-category

可參考Procedure Category Codes(SNOMED CT)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。


A code that classifies a procedure for searching, sorting and display purposes.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. Procedure.code
Definition

所進行的特定處置。如果不能對處置的確切種類進行編碼,則使用文字(例如:「腹腔鏡闌尾切除術」)。


The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").

Short處置的識別碼。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。Identification of the procedure
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control10..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code

可參考Procedure Codes(SNOMED CT)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。


A code to identify a specific procedure .

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Requirements

0..1主要僅用於解釋敘述性的resource。


0..1 to account for primarily narrative only resources.

Alternate Namestype
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. Procedure.code.id
Definition

resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。


Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Short唯一可識別ID,以供資料項目間相互參照。Unique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
38. Procedure.code.extension
Definition

擴充的資料項目


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擴充的資料項目Additional content defined by implementations
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。


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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-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())
SlicingThis element introduces a set of slices on Procedure.code.extension. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ url
40. Procedure.code.coding
Definition

由專門術語系統(terminology system)所定義之代碼的參照。


A reference to a code defined by a terminology system.

Short由專門術語系統(terminology system)定義的代碼Code defined by a terminology system
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Control0..*
This element is affected by the following invariants: ele-1
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼


Allows for alternative encodings within a code system, and translations to other code systems.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Procedure.code.coding. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • pattern @ $this
42. Procedure.code.coding:icd10-pcs-2021
Slice Nameicd10-pcs-2021
Definition

由專門術語系統(terminology system)所定義之代碼的參照。


A reference to a code defined by a terminology system.

Short此為臺灣衛生福利部中央健康保險署維護之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。Code defined by a terminology system
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Control0..1*
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from For codes, see 臺灣2021年中文版ICD-10-PCS值集: 病情、問題或診斷的識別;應填入臺灣2021年中文版ICD-10-PCS值集值集中的其中一個代碼。
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼


Allows for alternative encodings within a code system, and translations to other code systems.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
44. Procedure.code.coding:icd10-pcs-2014
Slice Nameicd10-pcs-2014
Definition

由專門術語系統(terminology system)所定義之代碼的參照。


A reference to a code defined by a terminology system.

Short此為臺灣衛生福利部中央健康保險署維護之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。Code defined by a terminology system
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Control0..1*
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from For codes, see 臺灣2014年中文版ICD-10-PCS值集: 病情、問題或診斷的識別;應填入臺灣2014年中文版ICD-10-PCS值集值集中的其中一個代碼。
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼


Allows for alternative encodings within a code system, and translations to other code systems.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
46. Procedure.code.coding:icd9-cm-2001
Slice Nameicd9-cm-2001
Definition

由專門術語系統(terminology system)所定義之代碼的參照


A reference to a code defined by a terminology system.

Short由專門術語系統(terminology system)定義的代碼Code defined by a terminology system
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,例如:SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Control0..1*
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from For codes, see 臺灣2001年中文版ICD-9-CM值集
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。


Allows for alternative encodings within a code system, and translations to other code systems.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. Procedure.code.coding:medical-service-payment
Slice Namemedical-service-payment
Definition

由專門術語系統(terminology system)所定義之代碼的參照。


A reference to a code defined by a terminology system.

Short此為中央健康保險署(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。Code defined by a terminology system
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Control0..1*
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from For codes, see 臺灣藥品使用頻率值集: 病情、問題或診斷的識別;應填入臺灣2014年中文版ICD-10-PCS值集值集中的其中一個代碼。
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼


Allows for alternative encodings within a code system, and translations to other code systems.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. Procedure.code.coding:sct-procedures-ips
Slice Namesct-procedures-ips
Definition

由專門術語系統(terminology system)所定義之代碼的參照。


A reference to a code defined by a terminology system.

Short此為SNOMED CT處置代碼,若機構已有購買相關授權,亦可使用。Code defined by a terminology system
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Control0..1*
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from For codes, see Procedures (SNOMED CT) - IPS: 病情、問題或診斷的識別;應填入Procedures - IPS值集中的其中一個代碼。
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼


Allows for alternative encodings within a code system, and translations to other code systems.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
52. Procedure.code.text
Definition

輸入資料的使用者所見/所選/所說的人類可讀文字表述,和(或)其代表使用者的預期含義。


A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Short概念的文字表示法Plain text representation of the concept
Comments

很多時候,此文字表述與其中一個代碼的顯示名稱相同。


Very often the text is the same as a displayName of one of the codings.

Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

專門術語中的代碼並不總是能捕捉人類使用的細微差別的正確意義,或者根本就沒有合適的代碼;這些情況下,文字表述被用來捕捉來源的全部意義。


The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
54. Procedure.subject
Definition

進行處置的病人、動物或實體集合(例如:特定的一群人)。


The person, animal or group on which the procedure was performed.

Short處置服務的對象Who the procedure was performed on
Control1..1
TypeReference(TW Core Patient, Patient, Group)
Is Modifierfalse
Must Supporttrue
Summarytrue
Alternate Namespatient
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
56. Procedure.encounter
Definition

此「處置(Procedure)」記載在哪次的「就醫(Encounter)」紀錄或者與此處置紀錄密切相關的「就醫(Encounter)」紀錄


The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated.

Short就醫(Encounter)紀錄作為處置的一部分Encounter created as part of
Comments

通常是此處置發生的就醫事件(Encounter),雖然有些活動可能在就醫結束之前或之後開始,但仍與就醫事件的情境有關。這筆紀錄表明與此處置紀錄相關的就醫事件。


This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.

Control0..1
TypeReference(TW Core Encounter, Encounter)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
58. Procedure.performed[x]
Definition

進行處置的估計或實際日期、日期時間、時間區間或年齡。允許一個時間區間來支持跨越一個日期以上的複雜處置,也允許捕捉處置的執行時間長度。


Estimated or actual date, date-time, period, or age when the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured.

Short此處置何時執行的?When the procedure was performed
Comments

年齡一般用於病人報告其進行手術的年齡,像是20到25歲時。 dateTime支援一定的精度範圍,因為有些處置被報告為過去的處置,可能沒有毫秒的精度,而其他在就醫期間執行和記錄的處置可能有更精確的UTC時間戳記和時區。


Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone.

Control0..1
TypeChoice of: dateTime, Period, string, Age, Range
[x] NoteSee Choice of Data Types for further information about how to use [x]
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Must Support TypesdateTime
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
60. Procedure.recorder
Definition

記錄處置內容並對其內容負責的個人


Individual who recorded the record and takes responsibility for its content.

Short誰記錄此處置Who recorded the procedure
Control0..1
TypeReference(TW Core Patient, TW Core Practitioner, PractitionerRole, RelatedPerson, Patient, Practitioner)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
62. Procedure.asserter
Definition

提出此處置說明的人


Individual who is making the procedure statement.

Short聲稱有此處置的人Person who asserts this procedure
Control0..1
TypeReference(TW Core Patient, RelatedPerson, TW Core Practitioner, PractitionerRole, Patient, Practitioner)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
64. Procedure.performer
Definition

限於「真正的」人而不是設備


Limited to "real" people rather than equipment.

Short執行處置的人員The people who performed the procedure
Control0..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
66. Procedure.performer.id
Definition

resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。


Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Short唯一可識別ID,以供資料項目間相互參照。Unique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
68. Procedure.performer.extension
Definition

可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。


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擴充的資料項目Additional content defined by implementations
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。


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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-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())
70. Procedure.performer.modifierExtension
Definition

可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。 修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。


May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Short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。Extensions that cannot be ignored even if unrecognized
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。


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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互通性。更多訊息,請參見修飾用的資料項目擴充之定義


Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-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())
72. Procedure.performer.function
Definition

區分執行者在處置中的參與型別,例如:外科醫生、麻醉師、內視鏡醫生。


Distinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist.

Short執行的型別Type of performance
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control0..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-role

可參考Procedure Performer Role Codes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。


A code that identifies the role of a performer of the procedure.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Requirements

允許針對不同執行者的參與型別進行澄清以消除歧義


Allows disambiguation of the types of involvement of different performers.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
74. Procedure.performer.actor
Definition

參與處置的健康照護服務提供人員


The practitioner who was involved in the procedure.

Short參照至健康照護服務提供人員The reference to the practitioner
Control1..1
TypeReference(TW Core Practitioner, PractitionerRole, TW Core Organization Hospital Department, TW Core Patient, RelatedPerson, Device, Practitioner, Organization, Patient)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summarytrue
Requirements

一個參照至裝置(Device)的使用案例,例如:心律調整器。


A reference to Device supports use cases, such as pacemakers.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
76. Procedure.performer.onBehalfOf
Definition

此裝置或健康照護服務提供人員所代表的機構


The organization the device or practitioner was acting on behalf of.

Short此裝置(Device)或健康照護服務提供人員所屬機構(Organization)Organization the device or practitioner was acting for
Control0..1
TypeReference(TW Core Organization Hospital Department, Organization)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

健康照護服務提供人員和裝置可以與多個機構相關聯,此資料項目表明他們在執行行動時代表哪個機構。


Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
78. Procedure.location
Definition

實際發生處置的地點(Location)。例如:新生兒在家裡出生、在餐廳做氣管切開術。


The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.

Short處置發生的地點(Location)?Where the procedure happened
Control0..1
TypeReference(Location)
Is Modifierfalse
Summarytrue
Requirements

將一個處置與可能保存紀錄的地點(Location)聯繫起來


Ties a procedure to where the records are likely kept.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
80. Procedure.reasonCode
Definition

進行此處置的原因代碼。這可能是某種型別的編碼,也可能只是文字表述。


The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text.

Short處置執行原因代碼Coded reason procedure performed
Comments

當一個代碼足以描述原因時,使用Procedure.reasonCode。當參照一個resource時,使用Procedure.reasonReference以傳達更多的資訊,如發病日期。Procedure.reasonCode和Procedure.reasonReference不應該是重複的。對於一個單一的原因,Procedure.reasonCode或Procedure.reasonReference都可以被使用。Procedure.reasonCode可以是一個摘要代碼,或者Procedure.reasonReference可以用Condition | Observation | Procedure | DiagnosticReport | DocumentReference來參照一個非常精確的原因定義。如果Procedure.reasonCode和Procedure.reasonReference描述的是處置的不同原因,則兩者都可以使用。


Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.

Control0..*
This element is affected by the following invariants: ele-1
BindingFor example codes, see ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reason

可[參考Procedure Reason Codes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。


A code that identifies the reason a procedure is required.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
82. Procedure.reasonReference
Definition

為什麼進行此處置的原因


The justification of why the procedure was performed.

Short執行此處置的原因The justification that the procedure was performed
Comments

一個處置有可能成為另一個處置(如C-Section)的理由(如硬膜外)。其他的例子包括擴張的內窺鏡檢查和活檢(診斷和治療的結合)。 當一個代碼充分地描述了原因時,使用Procedure.reasonCode。當引用一個resource時,使用Procedure.reasonReference,這樣可以傳達更多的資訊,如發病日期。Procedure.reasonCode和Procedure.reasonReference不應該是重複的。對於一個單一的原因,Procedure.reasonCode或Procedure.reasonReference都可以被使用。Procedure.reasonCode可以是一個摘要代碼,或者Procedure.reasonReference可以用Condition | Observation | Procedure | DiagnosticReport | DocumentReference來引用一個非常精確的原因定義。如果Procedure.reasonCode和Procedure.reasonReference描述的是處置的不同原因,則兩者都可以使用。


It is possible for a procedure to be a reason (such as C-Section) for another procedure (such as an epidural). Other examples include endoscopy for dilatation and biopsy (a combination of diagnostic and therapeutic use). Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.

Control0..*
TypeReference(TW Core Condition, TW Core Observation Laboratory Result, TW Core Procedure, DiagnosticReport, DocumentReference, Condition, Observation, Procedure)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
84. Procedure.bodySite
Definition

詳細和結構化的解剖學位置資訊。允許多個位置—例如:一個病灶的多個活體組織切片。


Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.

Short目標身體部位。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。Target body sites
Comments

如果案例需要BodySite resource的屬性(例如:識別和各別追蹤),那麼就使用標準擴充[procedure-targetbodystructure](擴充-procedure-targetbodystructure.html)。


If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension procedure-targetbodystructure.

Control0..*
This element is affected by the following invariants: ele-1
BindingFor example codes, see SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site

可參考SNOMED CT Body Structures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。


Codes describing anatomical locations. May include laterality.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
86. Procedure.outcome
Definition

處置的結果—它是否解決了當初執行處置所要解決的問題?


The outcome of the procedure - did it resolve the reasons for the procedure being performed?

Short處置的結果。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。The result of procedure
Comments

如果結果只包含敘述性文字,可用CodeableConcept.text來說明。


If outcome contains narrative text only, it can be captured using the CodeableConcept.text.

Control0..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcome

可參考Procedure Outcome Codes(SNOMED CT)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。


An outcome of a procedure - whether it was resolved or otherwise.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
88. Procedure.report
Definition

這可能是組織學結果、病理學報告、手術報告等。


This could be a histology result, pathology report, surgical report, etc.

Short此處置產生的任何報告Any report resulting from the procedure
Comments

有可能會有多份報告—例如:如果這是一個需要進行多次活體組織切片的處置,會產生一些解剖病理報告。


There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports.

Control0..*
TypeReference(DiagnosticReport, DocumentReference, Composition)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
90. Procedure.complication
Definition

在處置過程中,或在處置後不久發生的任何併發症。這些通常與紀錄分開追蹤,紀錄通常描述處置本身,而不是任何 「處置後」的問題。


Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the notes, which will typically describe the procedure itself rather than any 'post procedure' issues.

Short處置後的併發症Complication following the procedure
Comments

如果併發症僅由敘述性文字表達,可用CodeableConcept.text來說明。


If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.

Control0..*
This element is affected by the following invariants: ele-1
BindingFor example codes, see Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code

可參考Condition/Problem/Diagnosis Codes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。


Codes describing complications that resulted from a procedure.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
92. Procedure.complicationDetail
Definition

在處置過程中或在執行結束後立即發生的任何併發症


Any complications that occurred during the procedure, or in the immediate post-performance period.

Short處置後發生的病情、問題或診斷A condition that is a result of the procedure
Control0..*
TypeReference(TW Core Condition, Condition)
Is Modifierfalse
Summaryfalse
Requirements

這是用來記錄作為處置結果的病情、問題或診斷,而不是作為處置原因的病情、問題或診斷。


This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
94. Procedure.followUp
Definition

如果該處置需要特定的後續行動—例如拆除縫線。 後續行動可以表現為一個簡單的說明,也可能是更複雜的,在這種情況下,可以使用CarePlan resource。


If the procedure required specific follow up - e.g. removal of sutures. The follow up may be represented as a simple note or could potentially be more complex, in which case the CarePlan resource can be used.

Short追蹤說明。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。Instructions for follow up
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control0..*
This element is affected by the following invariants: ele-1
BindingFor example codes, see ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followup

可參考Procedure Follow up Codes(SNOMED CT)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。


Specific follow up required for a procedure e.g. removal of sutures.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
96. Procedure.note
Definition

關於此處置的任何其他註釋和意見


Any other notes and comments about the procedure.

Short關於此處置的附加資訊Additional information about the procedure
Control0..*
TypeAnnotation
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
98. Procedure.focalDevice
Definition

植入、移除或以其他方式操作的裝置(校準、更換電池、安裝義肢、安裝傷口真空裝置等),是處置的重點部分。


A device that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.

Short處理、植入的或移除的裝置Manipulated, implanted, or removed device
Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
100. Procedure.focalDevice.id
Definition

resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。


Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Short唯一可識別ID,以供資料項目間相互參照。Unique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
102. Procedure.focalDevice.extension
Definition

可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。


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擴充的資料項目Additional content defined by implementations
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。


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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-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())
104. Procedure.focalDevice.modifierExtension
Definition

可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。 修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。


May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Short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。Extensions that cannot be ignored even if unrecognized
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。


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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互通性。更多訊息,請參見修飾用的資料項目擴充之定義


Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-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())
106. Procedure.focalDevice.action
Definition

處置過程中,設備改變的類型。


The kind of change that happened to the device during the procedure.

Short改變裝置的種類Kind of change to device
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control0..1
This element is affected by the following invariants: ele-1
BindingThe codes SHOULD be taken from ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-action

鼓勵使用Procedure Device Action Codes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。


A kind of change that happened to the device during the procedure.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
108. Procedure.focalDevice.manipulated
Definition

在處置中被處理(改變)的裝置


The device that was manipulated (changed) during the procedure.

Short被改變的裝置Device that was changed
Control1..1
TypeReference(Device)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
110. Procedure.usedReference
Definition

指明藥品、裝置和作為處置一部分的任何其他物質


Identifies medications, devices and any other substance used as part of the procedure.

Short處置中使用的項目/物品Items used during procedure
Comments

對於實際植入或取出的裝置,使用Procedure.device。


For devices actually implanted or removed, use Procedure.device.

Control0..*
TypeReference(Device, Medication, Substance)
Is Modifierfalse
Summaryfalse
Requirements

用於追蹤污染等


Used for tracking contamination, etc.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
112. Procedure.usedCode
Definition

指明作為處置的一部分而使用的編碼項目


Identifies coded items that were used as part of the procedure.

Short處置中使用的項目之代碼Coded items used during the procedure
Comments

對於實際植入或取出的裝置,使用Procedure.device。


For devices actually implanted or removed, use Procedure.device.

Control0..*
This element is affected by the following invariants: ele-1
BindingFor example codes, see FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kind

可參考FHIR Device Types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。


Codes describing items used during a procedure.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be found here

0. Procedure
Definition

正在或曾經對病人執行的動作。這可以是像手術這樣的身體介入,也可以是像長照服務、諮詢或催眠療法這樣的非侵入性介入。HL7 FHIR官網另有提到的例子包括例如包括診斷處置、內視鏡處置、活體組織切片、諮詢、物理治療、個人支持服務、日照服務、非緊急運輸、改善家居設施、健身活動等。處置可以由醫護人員、服務提供人員、朋友或親屬或在某些情況下由病人自己執行。

Short正在或曾經對病人執行的動作
Control0..*
Is Modifierfalse
Summaryfalse
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
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 (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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. Procedure.id
Definition

resource的邏輯ID,在resource的URL中使用。一旦指定,這個值永遠不會改變。

Short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。
Comments

一個resource使用新增操作(create operation)提交給伺服器時是此resource唯一沒有id的時刻

Control0..1
Typeid
Is Modifierfalse
Summarytrue
4. Procedure.meta
Definition

關於resource的metadata。這是由基礎建設維護的內容。對內容的改變可能並不總是與resource的版本改變相關。

Short此Procedure Resource的metadata
Control0..1
TypeMeta
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
6. Procedure.implicitRules
Definition

構建resource時遵循的一系列規則的參照,在處理內容時必須理解這些規則。通常這是IG定義特殊規則及其他profiles的參照。

Short創建此內容所依據的一組規則
Comments

宣告這套規則限制了內容只能被有限的貿易夥伴所理解。這從本質上限制了資料的長期有用性。然而,現有的健康生態體系高度分裂,還沒有準備好以普遍可計算的方式定義、收集和交換資料。只要有可能,實作者和/或規範編寫者應該避免使用這個資料項目。通常,在使用時,此URL是對實作指引的參照,此指引將這些特殊規則與其他profiles、value sets等一起定義為其敘述的一部分。

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. Procedure.language
Definition

編寫此resource的基礎語言

Short用以表述Procedure Resource內容的語言
Comments

提供語言是為了支援索引和可存取性(通常,文字表述轉語音等服務使用此語言標籤)。html lanuage tag適用於此敘述。resource上的語言標籤可用於指定從resource中的資料所產成的其他表述之語言。不是所有的內容都必須使用此基礎語言。不應該假定Resource.language自動適用於敘述。如果指定語言,它也應該被指定在html中的div元素(關於xml:lang和html lang屬性之間的關係,見HTML5中的規則)。

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages: 人類語言;鼓勵使用CommonLanguages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。
Additional BindingsPurpose
AllLanguagesMax Binding
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Example<br/><b>Value</b>:zh-TW
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. Procedure.text
Definition

人可讀的敘述,包含resource的摘要,可用於向人表述resource的內容。敘述不需要對所有的結構化資料進行編碼,但需要包含足夠的細節使人在閱讀敘述時理解「臨床安全性」。resource定義可定義哪些內容應該在敘述中表示,以確保臨床安全。

ShortProcedure Resource之內容摘要以供人閱讀
Comments

內嵌(contained)的resource沒有敘述,非內嵌(contained)的resource則 建議應該(SHOULD) 有敘述。在某些情況下,resource可能只有文字表述,很少或沒有額外的離散資料(只要滿足所有minOccurs=1的資料項目)。這對於來自舊有系統的資料可能是必要的,在這些系統中,從 「文字表述區塊(text blob) 」獲取訊息,或者文字表述是額外的原始輸入或敘述,而編碼訊息是後來添加的。

Control0..1
TypeNarrative
Is Modifierfalse
Must Supporttrue
Summaryfalse
Alternate Namesnarrative, html, xhtml, display
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. Procedure.contained
Definition

這些resource內嵌(contains)的resource不會另外存於任何FHIR伺服器,意即它們無法在任何FHIR伺服器中被找到,也無法有自己獨立的資料異動/交易(transaction)範圍。

Short內嵌的(contained)、行內的Resources
Comments

當內容可以從任何FHIR伺服器找到時,不應該以內嵌(contained)resource的方式呈現,因為一旦識別丟失,要再次恢復它是非常困難的(並且取決於情境)。內嵌(contained)的resource可在它們的meta資料項目中表述profiles和tag(標籤),但 必須沒有(SHALL NOT) 資訊安全標號(security labels)。

Control0..*
TypeResource
Is Modifierfalse
Summaryfalse
Alternate Namesinline resources, anonymous resources, contained resources
14. Procedure.extension
Definition

可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

Short擴充的資料項目
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Invariantsele-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())
16. Procedure.modifierExtension
Definition

可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。 修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。

Short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。
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互通性。更多訊息,請參見修飾用的資料項目擴充之定義

Invariantsele-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())
18. Procedure.identifier
Definition

由執行者或其他系統指定給此處置的業務用識別碼,即使此resource作更新及在伺服器之間的傳遞,此識別碼仍保持不變。

Short此處置的外部識別碼
Comments

這是一個業務識別碼,不是一個resource識別碼(詳見討論)。最好的做法是該識別碼只出現在單個resource實例上,但是業務實務有可能會規定可以在多個resource實例中具有相同識別碼—甚至可能具有不同的resource型例。例如:多個 「Patient(病人)」和 「Person(個人)」resource實例可能共用同一個社會保險號碼。

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Is Modifierfalse
Summarytrue
Requirements

允許識別各參與系統所知的此處置資訊,並在各伺服器之間保持一致的方式。

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. Procedure.instantiatesCanonical
Definition

指向此處置全部或部分遵守的FHIR定義的計畫書(protocol)、指南(guideline)、醫令集(orderset)或其他定義的URL。

Short實例化FHIR計畫書(protocol)或定義
Control0..*
Typecanonical(PlanDefinition, ActivityDefinition, Measure, OperationDefinition, Questionnaire)
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. Procedure.instantiatesUri
Definition

指向此處置全部或部分的外部維護之計畫書(protocol)、指南(guideline)、醫令集(orderset)或其他定義的URL。

Short實例化外部計畫書(protocol)或定義
Comments

這可能是一個HTML頁面、PDF等,也可能只是一個不可分解的URI識別碼。

Control0..*
Typeuri
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. Procedure.basedOn
Definition

對一個resource的參照,此resource包含此處置請求的細節。

Short此Procedure是基於什麼而履行?
Control0..*
TypeReference(CarePlan, ServiceRequest)
Is Modifierfalse
Summarytrue
Alternate Namesfulfills
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. Procedure.partOf
Definition

這個特定的處置是一個更大的事件中的一個組成部分或步驟

Short參照事件的一部分
Comments

MedicationAdministration.partOf有一個Procedure參照,但這不是一個迴圈參照。例如:麻醉的給藥(MedicationAdministration)是手術處置的一部分(MedicationAdministration.partOf = Procedure)。例如:為靜脈給藥插入靜脈口的處置是給藥的一部分(Procedure.partOf = MedicationAdministration)。

Control0..*
TypeReference(TW Core Procedure, TW Core Observation Laboratory Result, MedicationAdministration)
Is Modifierfalse
Summarytrue
Alternate Namescontainer
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. Procedure.status
Definition

一個指定處置當前狀態的代碼。一般來說,它是進行中或完成的狀態。

Shortpreparation | in-progress | not-done |on-hold |stopped | completed | entered-in-error | unknown
Comments

「未知」代碼不能用來表達其他狀態。當其中一個狀態適用時但編輯系統不知道此處置的當前狀態,應該使用「未知」代碼。

Control1..1
BindingThe codes SHALL be taken from EventStatus: 應填入EventStatus值集中的其中一個代碼
Typecode
Is Modifiertrue because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. Procedure.statusReason
Definition

捕捉Procedure當前狀態的原因

Short當前狀態的原因。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。
Comments

這通常只用於「例外」狀態像是「未完成」、「暫停」或「終止」。執行此處置的原因是在reasonCode中說明,而不是在這裡。

Control0..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see ProcedureNotPerformedReason(SNOMED-CT): 可參考Procedure Not Performed Reason(SNOMED-CT)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。
TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Alternate NamesSuspended Reason, Cancelled Reason
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. Procedure.category
Definition

對處置進行分類的代碼(例如:「手術處置」)。主要為了搜尋、排序和顯示時使用。

Short處置的分類。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control0..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see ProcedureCategoryCodes(SNOMEDCT): 可參考Procedure Category Codes(SNOMED CT)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。
TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. Procedure.code
Definition

所進行的特定處置。如果不能對處置的確切種類進行編碼,則使用文字(例如:「腹腔鏡闌尾切除術」)。

Short處置的識別碼。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control1..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see ProcedureCodes(SNOMEDCT): 可參考Procedure Codes(SNOMED CT)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。
TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Requirements

0..1主要僅用於解釋敘述性的resource。

Alternate Namestype
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. Procedure.code.id
Definition

resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。

Short唯一可識別ID,以供資料項目間相互參照。
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
38. Procedure.code.extension
Definition

擴充的資料項目

Short擴充的資料項目
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Invariantsele-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())
SlicingThis element introduces a set of slices on Procedure.code.extension. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ url
40. Procedure.code.coding
Definition

由專門術語系統(terminology system)所定義之代碼的參照。

Short由專門術語系統(terminology system)定義的代碼
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Control0..*
This element is affected by the following invariants: ele-1
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Procedure.code.coding. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • pattern @ $this
42. Procedure.code.coding:icd10-pcs-2021
Slice Nameicd10-pcs-2021
Definition

由專門術語系統(terminology system)所定義之代碼的參照。

Short此為臺灣衛生福利部中央健康保險署維護之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。
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Control0..1
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from 臺灣2021年中文版ICD-10-PCS值集: 病情、問題或診斷的識別;應填入臺灣2021年中文版ICD-10-PCS值集值集中的其中一個代碼。
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
44. Procedure.code.coding:icd10-pcs-2014
Slice Nameicd10-pcs-2014
Definition

由專門術語系統(terminology system)所定義之代碼的參照。

Short此為臺灣衛生福利部中央健康保險署維護之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。
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Control0..1
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from 臺灣2014年中文版ICD-10-PCS值集: 病情、問題或診斷的識別;應填入臺灣2014年中文版ICD-10-PCS值集值集中的其中一個代碼。
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
46. Procedure.code.coding:icd9-cm-2001
Slice Nameicd9-cm-2001
Definition

由專門術語系統(terminology system)所定義之代碼的參照

Short由專門術語系統(terminology system)定義的代碼
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,例如:SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Control0..1
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from 臺灣2001年中文版ICD-9-CM值集
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. Procedure.code.coding:medical-service-payment
Slice Namemedical-service-payment
Definition

由專門術語系統(terminology system)所定義之代碼的參照。

Short此為中央健康保險署(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。
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Control0..1
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from 臺灣藥品使用頻率值集: 病情、問題或診斷的識別;應填入臺灣2014年中文版ICD-10-PCS值集值集中的其中一個代碼。
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. Procedure.code.coding:sct-procedures-ips
Slice Namesct-procedures-ips
Definition

由專門術語系統(terminology system)所定義之代碼的參照。

Short此為SNOMED CT處置代碼,若機構已有購買相關授權,亦可使用。
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Control0..1
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from Procedures (SNOMED CT) - IPS: 病情、問題或診斷的識別;應填入Procedures - IPS值集中的其中一個代碼。
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
52. Procedure.code.text
Definition

輸入資料的使用者所見/所選/所說的人類可讀文字表述,和(或)其代表使用者的預期含義。

Short概念的文字表示法
Comments

很多時候,此文字表述與其中一個代碼的顯示名稱相同。

Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

專門術語中的代碼並不總是能捕捉人類使用的細微差別的正確意義,或者根本就沒有合適的代碼;這些情況下,文字表述被用來捕捉來源的全部意義。

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
54. Procedure.subject
Definition

進行處置的病人、動物或實體集合(例如:特定的一群人)。

Short處置服務的對象
Control1..1
TypeReference(TW Core Patient)
Is Modifierfalse
Must Supporttrue
Summarytrue
Alternate Namespatient
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
56. Procedure.encounter
Definition

此「處置(Procedure)」記載在哪次的「就醫(Encounter)」紀錄或者與此處置紀錄密切相關的「就醫(Encounter)」紀錄

Short就醫(Encounter)紀錄作為處置的一部分
Comments

通常是此處置發生的就醫事件(Encounter),雖然有些活動可能在就醫結束之前或之後開始,但仍與就醫事件的情境有關。這筆紀錄表明與此處置紀錄相關的就醫事件。

Control0..1
TypeReference(TW Core Encounter)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
58. Procedure.performed[x]
Definition

進行處置的估計或實際日期、日期時間、時間區間或年齡。允許一個時間區間來支持跨越一個日期以上的複雜處置,也允許捕捉處置的執行時間長度。

Short此處置何時執行的?
Comments

年齡一般用於病人報告其進行手術的年齡,像是20到25歲時。 dateTime支援一定的精度範圍,因為有些處置被報告為過去的處置,可能沒有毫秒的精度,而其他在就醫期間執行和記錄的處置可能有更精確的UTC時間戳記和時區。

Control0..1
TypeChoice of: dateTime, Period, string, Age, Range
[x] NoteSee Choice of Data Types for further information about how to use [x]
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Must Support TypesdateTime
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
60. Procedure.recorder
Definition

記錄處置內容並對其內容負責的個人

Short誰記錄此處置
Control0..1
TypeReference(TW Core Patient, TW Core Practitioner, PractitionerRole, RelatedPerson)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
62. Procedure.asserter
Definition

提出此處置說明的人

Short聲稱有此處置的人
Control0..1
TypeReference(TW Core Patient, RelatedPerson, TW Core Practitioner, PractitionerRole)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
64. Procedure.performer
Definition

限於「真正的」人而不是設備

Short執行處置的人員
Control0..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
66. Procedure.performer.id
Definition

resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。

Short唯一可識別ID,以供資料項目間相互參照。
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
68. Procedure.performer.extension
Definition

可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

Short擴充的資料項目
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Invariantsele-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())
70. Procedure.performer.modifierExtension
Definition

可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。 修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。

Short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。
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互通性。更多訊息,請參見修飾用的資料項目擴充之定義

Invariantsele-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())
72. Procedure.performer.function
Definition

區分執行者在處置中的參與型別,例如:外科醫生、麻醉師、內視鏡醫生。

Short執行的型別
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control0..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see ProcedurePerformerRoleCodes: 可參考Procedure Performer Role Codes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。
TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Requirements

允許針對不同執行者的參與型別進行澄清以消除歧義

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
74. Procedure.performer.actor
Definition

參與處置的健康照護服務提供人員

Short參照至健康照護服務提供人員
Control1..1
TypeReference(TW Core Practitioner, PractitionerRole, TW Core Organization Hospital Department, TW Core Patient, RelatedPerson, Device)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summarytrue
Requirements

一個參照至裝置(Device)的使用案例,例如:心律調整器。

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
76. Procedure.performer.onBehalfOf
Definition

此裝置或健康照護服務提供人員所代表的機構

Short此裝置(Device)或健康照護服務提供人員所屬機構(Organization)
Control0..1
TypeReference(TW Core Organization Hospital Department)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

健康照護服務提供人員和裝置可以與多個機構相關聯,此資料項目表明他們在執行行動時代表哪個機構。

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
78. Procedure.location
Definition

實際發生處置的地點(Location)。例如:新生兒在家裡出生、在餐廳做氣管切開術。

Short處置發生的地點(Location)?
Control0..1
TypeReference(Location)
Is Modifierfalse
Summarytrue
Requirements

將一個處置與可能保存紀錄的地點(Location)聯繫起來

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
80. Procedure.reasonCode
Definition

進行此處置的原因代碼。這可能是某種型別的編碼,也可能只是文字表述。

Short處置執行原因代碼
Comments

當一個代碼足以描述原因時,使用Procedure.reasonCode。當參照一個resource時,使用Procedure.reasonReference以傳達更多的資訊,如發病日期。Procedure.reasonCode和Procedure.reasonReference不應該是重複的。對於一個單一的原因,Procedure.reasonCode或Procedure.reasonReference都可以被使用。Procedure.reasonCode可以是一個摘要代碼,或者Procedure.reasonReference可以用Condition | Observation | Procedure | DiagnosticReport | DocumentReference來參照一個非常精確的原因定義。如果Procedure.reasonCode和Procedure.reasonReference描述的是處置的不同原因,則兩者都可以使用。

Control0..*
This element is affected by the following invariants: ele-1
BindingFor example codes, see ProcedureReasonCodes: 可[參考Procedure Reason Codes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。
TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
82. Procedure.reasonReference
Definition

為什麼進行此處置的原因

Short執行此處置的原因
Comments

一個處置有可能成為另一個處置(如C-Section)的理由(如硬膜外)。其他的例子包括擴張的內窺鏡檢查和活檢(診斷和治療的結合)。 當一個代碼充分地描述了原因時,使用Procedure.reasonCode。當引用一個resource時,使用Procedure.reasonReference,這樣可以傳達更多的資訊,如發病日期。Procedure.reasonCode和Procedure.reasonReference不應該是重複的。對於一個單一的原因,Procedure.reasonCode或Procedure.reasonReference都可以被使用。Procedure.reasonCode可以是一個摘要代碼,或者Procedure.reasonReference可以用Condition | Observation | Procedure | DiagnosticReport | DocumentReference來引用一個非常精確的原因定義。如果Procedure.reasonCode和Procedure.reasonReference描述的是處置的不同原因,則兩者都可以使用。

Control0..*
TypeReference(TW Core Condition, TW Core Observation Laboratory Result, TW Core Procedure, DiagnosticReport, DocumentReference)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
84. Procedure.bodySite
Definition

詳細和結構化的解剖學位置資訊。允許多個位置—例如:一個病灶的多個活體組織切片。

Short目標身體部位。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。
Comments

如果案例需要BodySite resource的屬性(例如:識別和各別追蹤),那麼就使用標準擴充[procedure-targetbodystructure](擴充-procedure-targetbodystructure.html)。

Control0..*
This element is affected by the following invariants: ele-1
BindingFor example codes, see SNOMEDCTBodyStructures: 可參考SNOMED CT Body Structures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。
TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
86. Procedure.outcome
Definition

處置的結果—它是否解決了當初執行處置所要解決的問題?

Short處置的結果。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。
Comments

如果結果只包含敘述性文字,可用CodeableConcept.text來說明。

Control0..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see ProcedureOutcomeCodes(SNOMEDCT): 可參考Procedure Outcome Codes(SNOMED CT)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。
TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
88. Procedure.report
Definition

這可能是組織學結果、病理學報告、手術報告等。

Short此處置產生的任何報告
Comments

有可能會有多份報告—例如:如果這是一個需要進行多次活體組織切片的處置,會產生一些解剖病理報告。

Control0..*
TypeReference(DiagnosticReport, DocumentReference, Composition)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
90. Procedure.complication
Definition

在處置過程中,或在處置後不久發生的任何併發症。這些通常與紀錄分開追蹤,紀錄通常描述處置本身,而不是任何 「處置後」的問題。

Short處置後的併發症
Comments

如果併發症僅由敘述性文字表達,可用CodeableConcept.text來說明。

Control0..*
This element is affected by the following invariants: ele-1
BindingFor example codes, see Condition/Problem/DiagnosisCodes: 可參考Condition/Problem/Diagnosis Codes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。
TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
92. Procedure.complicationDetail
Definition

在處置過程中或在執行結束後立即發生的任何併發症

Short處置後發生的病情、問題或診斷
Control0..*
TypeReference(TW Core Condition)
Is Modifierfalse
Summaryfalse
Requirements

這是用來記錄作為處置結果的病情、問題或診斷,而不是作為處置原因的病情、問題或診斷。

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
94. Procedure.followUp
Definition

如果該處置需要特定的後續行動—例如拆除縫線。 後續行動可以表現為一個簡單的說明,也可能是更複雜的,在這種情況下,可以使用CarePlan resource。

Short追蹤說明。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control0..*
This element is affected by the following invariants: ele-1
BindingFor example codes, see ProcedureFollowUpCodes(SNOMEDCT): 可參考Procedure Follow up Codes(SNOMED CT)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。
TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
96. Procedure.note
Definition

關於此處置的任何其他註釋和意見

Short關於此處置的附加資訊
Control0..*
TypeAnnotation
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
98. Procedure.focalDevice
Definition

植入、移除或以其他方式操作的裝置(校準、更換電池、安裝義肢、安裝傷口真空裝置等),是處置的重點部分。

Short處理、植入的或移除的裝置
Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
100. Procedure.focalDevice.id
Definition

resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。

Short唯一可識別ID,以供資料項目間相互參照。
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
102. Procedure.focalDevice.extension
Definition

可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

Short擴充的資料項目
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Invariantsele-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())
104. Procedure.focalDevice.modifierExtension
Definition

可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。 修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。

Short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。
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互通性。更多訊息,請參見修飾用的資料項目擴充之定義

Invariantsele-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())
106. Procedure.focalDevice.action
Definition

處置過程中,設備改變的類型。

Short改變裝置的種類
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control0..1
This element is affected by the following invariants: ele-1
BindingThe codes SHOULD be taken from ProcedureDeviceActionCodes: 鼓勵使用Procedure Device Action Codes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。
TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
108. Procedure.focalDevice.manipulated
Definition

在處置中被處理(改變)的裝置

Short被改變的裝置
Control1..1
TypeReference(Device)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
110. Procedure.usedReference
Definition

指明藥品、裝置和作為處置一部分的任何其他物質

Short處置中使用的項目/物品
Comments

對於實際植入或取出的裝置,使用Procedure.device。

Control0..*
TypeReference(Device, Medication, Substance)
Is Modifierfalse
Summaryfalse
Requirements

用於追蹤污染等

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
112. Procedure.usedCode
Definition

指明作為處置的一部分而使用的編碼項目

Short處置中使用的項目之代碼
Comments

對於實際植入或取出的裝置,使用Procedure.device。

Control0..*
This element is affected by the following invariants: ele-1
BindingFor example codes, see FHIRDeviceTypes: 可參考FHIR Device Types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。
TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))