This page is part of the 臺灣核心實作指引(TW Core IG) (v0.2.1: Releases) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
Active as of 2024-04-09 |
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/手術、內視鏡處置/手術、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/手術可以由醫護人員、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,此resource沒有id,它的id在resource被創建後由伺器分配/指定。 | ||||
4. Procedure.meta | |||||
Definition | 關於resource的metadata。這是由基礎建設維護的內容。內容的更改可能並不總是與resource的版本更改相關聯。 | ||||
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。通常這是對IG所定義之特殊規則及其他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交易夥伴所理解。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IG的參照,此IG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資料項目(關於xml:lang和html lang屬性之間的關係,見HTML5中的規則)。 | ||||
Binding | The codes SHOULD be taken from CommonLanguages (preferred to http://hl7.org/fhir/ValueSet/languages )人類語言;鼓勵使用CommonLanguages代碼表中的代碼,但不強制一定要使用此代碼表,你也可使用其他代碼表的代碼或單純以文字表示。
| ||||
Example | <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定義有哪些內容應該在敘述中表示,以確保臨床安全。 | ||||
Short | Procedure 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。有時resource可能只有文字表述,很少或沒有額外的結構化資料(只要滿足所有minOccurs=1的資料項目)。這可能出現在舊系統的資料,當資訊以 「文字表述區塊(text blob) 」的形式被取得,或者文字表述是原始輸入或說明,而編碼資訊稍後再添加。 | ||||
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,因為一旦失去識別,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,但不應該有安全標號(security labels)。 | ||||
14. Procedure.extension | |||||
Definition | 可用於表示不屬於此resource基本定義的額外資訊。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,必須(SHALL) 滿足一系列要求。 | ||||
Short | 擴充的資料項目 | ||||
Comments | 任何應用程式、專案或標準使用擴充時,都不應該帶有任何負面的聯想。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此resource的基本定義的額外資訊,並修改包含它所內嵌(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的資訊。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。雖然任何實作者都可以定義一個擴充,但在定義擴充時 必須(SHALL) 滿足一組要求。處理resource的應用程式需要檢查修飾用的擴充資料項目。 | ||||
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 | 任何應用程式、專案或標準使用擴充時,都不應該帶有任何負面的聯想。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允許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。這樣做有助於促進可互操作性,因為無需禁止實作者使用擴充,想要瞭解更多資訊,請參見[修飾用的資料項目擴充之定義](http://hl7.org/fhir/R4/extensibility.html#modifierExtension)。 | ||||
18. Procedure.identifier | |||||
Definition | 由執行者或其他系統指定給此處置/手術的業務用識別碼,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/手術的外部識別碼 | ||||
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。 | ||||
Note | This 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/手術資訊,並在各伺服器之間保持一致的方式。 | ||||
20. Procedure.instantiatesCanonical | |||||
Definition | 指向此處置/手術全部或部分遵守的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/手術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/手術請求的細節。 | ||||
Short | 此Procedure是基於什麼而履行 | ||||
26. Procedure.partOf | |||||
Definition | 這個特定的處置/手術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/手術的一部分(MedicationAdministration.partOf = Procedure)。例如:為靜脈給藥插入靜脈口的處置/手術是給藥的一部分(Procedure.partOf = MedicationAdministration)。 | ||||
Type | Reference(TW Core Procedure, TW Core Observation Laboratory Result, MedicationAdministration) | ||||
28. Procedure.status | |||||
Definition | 一個指定處置/手術當前狀態的代碼。一般來說,它是進行中或完成的狀態。 | ||||
Short | preparation | 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/手術的當前狀態,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。 | ||||
Binding | The codes SHALL be taken from EventStatus (required to http://hl7.org/fhir/ValueSet/event-status|4.0.1 )應填入所綁定值集中的其中一個代碼 | ||||
Must Support | true | ||||
30. Procedure.statusReason | |||||
Definition | 捕捉Procedure當前狀態的原因 | ||||
Short | 當前狀態的原因。 | ||||
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/手術的原因是在reasonCode中說明,而不是在這裡。 | ||||
Binding | Unless not suitable, these codes SHALL be taken from ProcedureNotPerformedReason(SNOMED-CT) (extensible to http://hl7.org/fhir/ValueSet/procedure-not-performed-reason )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
32. Procedure.category | |||||
Definition | 對處置/手術進行分類的代碼(例如:「手術處置/手術」)。主要為了搜尋、排序和顯示時使用。 | ||||
Short | 處置/手術的分類。 | ||||
Binding | Unless not suitable, these codes SHALL be taken from ProcedureCategoryCodes(SNOMEDCT) (extensible to http://hl7.org/fhir/ValueSet/procedure-category )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
34. Procedure.code | |||||
Definition | 所進行的特定處置/手術。如果不能對處置/手術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/手術的識別碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 | ||||
Control | 1..? | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Must Support | true | ||||
Requirements | 0..1主要僅用於解釋敘述性的resource。 | ||||
36. 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。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 | ||||
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 | ||||
Slicing | This element introduces a set of slices on Procedure.code.coding . The slices are unordered and Open, and can be differentiated using the following discriminators: | ||||
38. Procedure.code.coding:icd10-pcs-2021 | |||||
Slice Name | icd10-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(NHI)維護之2021年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 | ||||
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。 | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from 臺灣健保署2021年中文版ICD-10-PCS值集 (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw )處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
Must Support | 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 | ||||
40. Procedure.code.coding:icd10-pcs-2014 | |||||
Slice Name | icd10-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(NHI)維護之2014年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 | ||||
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。 | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from 臺灣健保署2014年中文版ICD-10-PCS值集 (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2014-tw )處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
Must Support | 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 | ||||
42. Procedure.code.coding:icd9-cm-2001 | |||||
Slice Name | icd9-cm-2001 | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from 臺灣健保署2001年中文版ICD-9-CM值集 (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw ) | ||||
Must Support | true | ||||
44. Procedure.code.coding:medical-service-payment | |||||
Slice Name | medical-service-payment | ||||
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(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。 | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from 臺灣衛福部統計處藥品使用頻率值集 (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/medication-frequency-tw )處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
Must Support | 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 | ||||
46. Procedure.code.coding:sct-procedures | |||||
Slice Name | sct-procedures | ||||
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/手術代碼,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。 | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from ProcedureCodes(SNOMEDCT) (required to http://hl7.org/fhir/ValueSet/procedure-code )處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
Must Support | 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 | ||||
48. 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 Support | true | ||||
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。 | ||||
50. Procedure.subject | |||||
Definition | 進行處置/手術的病人、動物或實體集合(例如:特定的一群人)。 | ||||
Short | 處置/手術服務的對象 | ||||
Type | Reference(TW Core Patient) | ||||
Must Support | true | ||||
52. Procedure.encounter | |||||
Definition | 此「處置/手術(Procedure)」記載在哪次的「就醫(Encounter)」紀錄或者與此處置/手術紀錄密切相關的「就醫(Encounter)」紀錄 | ||||
Short | 就醫(Encounter)紀錄作為處置/手術的一部分 | ||||
Comments | 通常是此處置/手術發生的就醫事件(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/手術紀錄相關的就醫事件。 | ||||
Type | Reference(TW Core Encounter) | ||||
54. Procedure.performed[x] | |||||
Definition | 進行處置/手術的估計或實際日期、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/手術,也允許捕捉處置/手術的執行時間長度。 | ||||
Short | 此處置/手術何時執行的? | ||||
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/手術被報告為過去的處置/手術,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/手術可能有更精確的UTC時間戳記和時區。 | ||||
Type | Choice of: dateTime, Period, string, Age, Range | ||||
[x] Note | See Choice of Data Types for further information about how to use [x] | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Must Support Types | dateTime | ||||
56. Procedure.recorder | |||||
Definition | 記錄處置/手術內容並對其內容負責的個人 | ||||
Short | 誰記錄此處置/手術 | ||||
Type | Reference(TW Core Patient, TW Core Practitioner, TW Core PractitionerRole, RelatedPerson) | ||||
58. Procedure.asserter | |||||
Definition | 提出此處置/手術說明的人 | ||||
Short | 聲稱有此處置/手術的人 | ||||
Type | Reference(TW Core Patient, RelatedPerson, TW Core Practitioner, TW Core PractitionerRole) | ||||
Must Support | true | ||||
Must Support Types | No must-support rules about the choice of types/profiles | ||||
60. Procedure.performer | |||||
Definition | 限於「真正的」人而不是設備 | ||||
Short | 執行處置/手術的人員 | ||||
Must Support | true | ||||
62. Procedure.performer.function | |||||
Definition | 區分執行者在處置/手術中的參與型別,例如:外科醫生、麻醉師、內視鏡醫生。 | ||||
Short | 執行的型別 | ||||
Binding | Unless not suitable, these codes SHALL be taken from ProcedurePerformerRoleCodes (extensible to http://hl7.org/fhir/ValueSet/performer-role )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
Type | CodeableConcept(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 | ||||
64. Procedure.performer.actor | |||||
Definition | 參與處置/手術的健康照護服務提供者 | ||||
Short | 參照至健康照護服務提供者 | ||||
Type | Reference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, TW Core Patient, RelatedPerson, Device) | ||||
Must Support | true | ||||
Must Support Types | No 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。 | ||||
66. Procedure.performer.onBehalfOf | |||||
Definition | 此裝置或健康照護服務提供者所代表的機構 | ||||
Short | 此裝置(Device)或健康照護服務提供者所屬機構(Organization) | ||||
Type | Reference(TW Core Organization) | ||||
Must Support | true | ||||
Requirements | 健康照護服務提供者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。 | ||||
68. Procedure.location | |||||
Definition | 實際發生處置/手術的地點(Location)。例如:新生兒在家裡出生、在餐廳做氣管切開術。 | ||||
Short | 處置/手術發生的地點(Location)? | ||||
Type | Reference(TW Core Location) | ||||
Requirements | 將一個處置/手術與可能保存紀錄的地點(Location)聯繫起來 | ||||
70. Procedure.reasonCode | |||||
Definition | 進行此處置/手術的原因代碼。這可能是某種型別的編碼,也可能只是文字表述。 | ||||
Short | 處置/手術執行原因代碼 | ||||
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/手術的不同原因,則兩者都可以使用。 | ||||
Binding | Unless not suitable, these codes SHALL be taken from ProcedureReasonCodes (extensible to http://hl7.org/fhir/ValueSet/procedure-reason )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
72. Procedure.reasonReference | |||||
Definition | 為什麼進行此處置/手術的原因 | ||||
Short | 執行此處置/手術的原因 | ||||
Comments | 一個處置/手術有可能成為另一個處置/手術(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/手術的不同原因,則兩者都可以使用。 | ||||
Type | Reference(TW Core Condition, TW Core Observation Laboratory Result, TW Core Procedure, DiagnosticReport, DocumentReference) | ||||
74. 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。 | ||||
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)。 | ||||
Binding | Unless not suitable, these codes SHALL be taken from SNOMEDCTBodyStructures (extensible to http://hl7.org/fhir/ValueSet/body-site )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Must Support | true | ||||
76. Procedure.outcome | |||||
Definition | 處置/手術的結果—它是否解決了當初執行處置/手術所要解決的問題? | ||||
Short | 處置/手術的結果。 | ||||
Comments | 如果結果只包含敘述性文字,可用CodeableConcept.text來說明。 | ||||
Binding | Unless not suitable, these codes SHALL be taken from ProcedureOutcomeCodes(SNOMEDCT) (extensible to http://hl7.org/fhir/ValueSet/procedure-outcome )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
78. 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/手術產生的任何報告 | ||||
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/手術,會產生一些解剖病理報告。 | ||||
80. Procedure.complication | |||||
Definition | 在處置/手術過程中,或在處置/手術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/手術本身,而不是任何 「處置/手術後」的問題。 | ||||
Short | 處置/手術後的併發症 | ||||
Comments | 如果併發症僅由敘述性文字表達,可用CodeableConcept.text來說明。 | ||||
Binding | Unless not suitable, these codes SHALL be taken from Condition/Problem/DiagnosisCodes (extensible to http://hl7.org/fhir/ValueSet/condition-code )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
82. Procedure.complicationDetail | |||||
Definition | 在處置/手術過程中或在執行結束後立即發生的任何併發症 | ||||
Short | 處置/手術後發生的病情、問題或診斷 | ||||
Type | Reference(TW Core Condition) | ||||
Requirements | 這是用來記錄作為處置/手術結果的病情、問題或診斷,而不是作為處置/手術原因的病情、問題或診斷。 | ||||
84. Procedure.followUp | |||||
Definition | 如果該處置/手術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。 | ||||
Binding | Unless not suitable, these codes SHALL be taken from ProcedureFollowUpCodes(SNOMEDCT) (extensible to http://hl7.org/fhir/ValueSet/procedure-followup )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
86. Procedure.note | |||||
Definition | 關於此處置/手術的任何其他註釋和意見 | ||||
Short | 關於此處置/手術的附加資訊 | ||||
88. 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/手術的重點部分。 | ||||
Short | 處理、植入的或移除的裝置 | ||||
90. Procedure.focalDevice.action | |||||
Definition | 處置/手術過程中,設備改變的類型。 | ||||
Short | 改變裝置的種類 | ||||
Binding | The codes SHOULD be taken from ProcedureDeviceActionCodes (preferred to http://hl7.org/fhir/ValueSet/device-action )鼓勵使用所綁定值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
92. Procedure.focalDevice.manipulated | |||||
Definition | 在處置/手術中被處理(改變)的裝置 | ||||
Short | 被改變的裝置 | ||||
94. Procedure.usedReference | |||||
Definition | 指明藥品、裝置和作為處置/手術一部分的任何其他物質 | ||||
Short | 處置/手術中使用的項目/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 | ||||
96. Procedure.usedCode | |||||
Definition | 指明作為處置/手術的一部分而使用的編碼項目 | ||||
Short | 處置/手術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。 | ||||
Binding | Unless not suitable, these codes SHALL be taken from FHIRDeviceTypes (extensible to http://hl7.org/fhir/ValueSet/device-kind )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
Type | CodeableConcept(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/手術、內視鏡處置/手術、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/手術可以由醫護人員、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 | ||||
Control | 0..* | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | dom-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,此resource沒有id,它的id在resource被創建後由伺器分配/指定。 The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||||
Control | 0..1 | ||||
Type | idstring | ||||
Is Modifier | false | ||||
Summary | true | ||||
4. Procedure.meta | |||||
Definition | 關於resource的metadata。這是由基礎建設維護的內容。內容的更改可能並不總是與resource的版本更改相關聯。 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 | ||||
Control | 0..1 | ||||
Type | Meta | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-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。通常這是對IG所定義之特殊規則及其他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交易夥伴所理解。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IG的參照,此IG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. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | true 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 Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-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資料項目(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). | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from CommonLanguageshttp://hl7.org/fhir/ValueSet/languages (preferred to http://hl7.org/fhir/ValueSet/languages )人類語言;鼓勵使用CommonLanguages代碼表中的代碼,但不強制一定要使用此代碼表,你也可使用其他代碼表的代碼或單純以文字表示。 A human language.
| ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Example | <br/><b>Value</b>:zh-TW | ||||
Invariants | ele-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定義有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. | ||||
Short | Procedure 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。有時resource可能只有文字表述,很少或沒有額外的結構化資料(只要滿足所有minOccurs=1的資料項目)。這可能出現在舊系統的資料,當資訊以 「文字表述區塊(text blob) 」的形式被取得,或者文字表述是原始輸入或說明,而編碼資訊稍後再添加。 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. | ||||
Control | 0..1 | ||||
Type | Narrative | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | narrative, html, xhtml, display | ||||
Invariants | ele-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,因為一旦失去識別,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,但不應該有安全標號(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. | ||||
Control | 0..* | ||||
Type | Resource | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | inline resources, anonymous resources, contained resources | ||||
14. Procedure.extension | |||||
Definition | 可用於表示不屬於此resource基本定義的額外資訊。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,必須(SHALL) 滿足一系列要求。 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 | 任何應用程式、專案或標準使用擴充時,都不應該帶有任何負面的聯想。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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) | ||||
16. Procedure.modifierExtension | |||||
Definition | 可以用來表示不屬於此resource的基本定義的額外資訊,並修改包含它所內嵌(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的資訊。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。雖然任何實作者都可以定義一個擴充,但在定義擴充時 必須(SHALL) 滿足一組要求。處理resource的應用程式需要檢查修飾用的擴充資料項目。 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 | 任何應用程式、專案或標準使用擴充時,都不應該帶有任何負面的聯想。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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them | ||||
Summary | false | ||||
Requirements | 修飾用的資料項目擴充允許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。這樣做有助於促進可互操作性,因為無需禁止實作者使用擴充,想要瞭解更多資訊,請參見[修飾用的資料項目擴充之定義](http://hl7.org/fhir/R4/extensibility.html#modifierExtension)。 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 Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) | ||||
18. Procedure.identifier | |||||
Definition | 由執行者或其他系統指定給此處置/手術的業務用識別碼,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/手術的外部識別碼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. | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 0..* | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | 允許識別各參與系統所知的此處置/手術資訊,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. | ||||
Invariants | ele-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/手術全部或部分遵守的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 | ||||
Control | 0..* | ||||
Type | canonical(PlanDefinition, ActivityDefinition, Measure, OperationDefinition, Questionnaire) | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-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/手術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. | ||||
Control | 0..* | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-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/手術請求的細節。 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 | ||||
Control | 0..* | ||||
Type | Reference(CarePlan, ServiceRequest) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Alternate Names | fulfills | ||||
Invariants | ele-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/手術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/手術的一部分(MedicationAdministration.partOf = Procedure)。例如:為靜脈給藥插入靜脈口的處置/手術是給藥的一部分(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). | ||||
Control | 0..* | ||||
Type | Reference(TW Core Procedure, TW Core Observation Laboratory Result, MedicationAdministration, Procedure, Observation) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Alternate Names | container | ||||
Invariants | ele-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/手術當前狀態的代碼。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. | ||||
Short | preparation | 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/手術的當前狀態,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. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1 (required to http://hl7.org/fhir/ValueSet/event-status|4.0.1 )應填入所綁定值集中的其中一個代碼 A code specifying the state of the procedure. | ||||
Type | code | ||||
Is Modifier | true 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 Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-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。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/手術的原因是在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. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reason (extensible to http://hl7.org/fhir/ValueSet/procedure-not-performed-reason )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 A code that identifies the reason a procedure was not performed. | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Alternate Names | Suspended Reason, Cancelled Reason | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
32. Procedure.category | |||||
Definition | 對處置/手術進行分類的代碼(例如:「手術處置/手術」)。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/手術的分類。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. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-category (extensible to http://hl7.org/fhir/ValueSet/procedure-category )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 A code that classifies a procedure for searching, sorting and display purposes. | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-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/手術。如果不能對處置/手術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/手術的識別碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。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. | ||||
Control | 10..1 This element is affected by the following invariants: ele-1 | ||||
Binding | For example codes, see ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code (example to http://hl7.org/fhir/ValueSet/procedure-code )A code to identify a specific procedure . | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
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 Names | type | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
36. 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。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。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. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | 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 Allows for alternative encodings within a code system, and translations to other code systems. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
Slicing | This element introduces a set of slices on Procedure.code.coding . The slices are unordered and Open, and can be differentiated using the following discriminators: | ||||
38. Procedure.code.coding:icd10-pcs-2021 | |||||
Slice Name | icd10-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(NHI)維護之2021年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。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. | ||||
Control | 0..1* This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from For codes, see 臺灣健保署2021年中文版ICD-10-PCS值集 (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw )處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | 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 Allows for alternative encodings within a code system, and translations to other code systems. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
40. Procedure.code.coding:icd10-pcs-2014 | |||||
Slice Name | icd10-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(NHI)維護之2014年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。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. | ||||
Control | 0..1* This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from For codes, see 臺灣健保署2014年中文版ICD-10-PCS值集 (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2014-tw )處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | 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 Allows for alternative encodings within a code system, and translations to other code systems. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
42. Procedure.code.coding:icd9-cm-2001 | |||||
Slice Name | icd9-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. | ||||
Control | 0..1* This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from For codes, see 臺灣健保署2001年中文版ICD-9-CM值集 (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw ) | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
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. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
44. Procedure.code.coding:medical-service-payment | |||||
Slice Name | medical-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 | 此為臺灣衛生福利部中央健康保險署(NHI)維護之醫療服務給付項目,主要針對申報使用,可免費使用,可依情境選用此代碼。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. | ||||
Control | 0..1* This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from For codes, see 臺灣衛福部統計處藥品使用頻率值集 (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/medication-frequency-tw )處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | 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 Allows for alternative encodings within a code system, and translations to other code systems. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
46. Procedure.code.coding:sct-procedures | |||||
Slice Name | sct-procedures | ||||
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/手術代碼,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. | ||||
Control | 0..1* This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from For codes, see ProcedureCodes(SNOMEDCT) (required to http://hl7.org/fhir/ValueSet/procedure-code )處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | 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 Allows for alternative encodings within a code system, and translations to other code systems. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
48. 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. | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
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. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
50. Procedure.subject | |||||
Definition | 進行處置/手術的病人、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/手術服務的對象Who the procedure was performed on | ||||
Control | 1..1 | ||||
Type | Reference(TW Core Patient, Patient, Group) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Alternate Names | patient | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
52. Procedure.encounter | |||||
Definition | 此「處置/手術(Procedure)」記載在哪次的「就醫(Encounter)」紀錄或者與此處置/手術紀錄密切相關的「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/手術的一部分Encounter created as part of | ||||
Comments | 通常是此處置/手術發生的就醫事件(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/手術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. | ||||
Control | 0..1 | ||||
Type | Reference(TW Core Encounter, Encounter) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
54. Procedure.performed[x] | |||||
Definition | 進行處置/手術的估計或實際日期、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/手術,也允許捕捉處置/手術的執行時間長度。 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/手術何時執行的?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/手術被報告為過去的處置/手術,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/手術可能有更精確的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. | ||||
Control | 0..1 | ||||
Type | Choice of: dateTime, Period, string, Age, Range | ||||
[x] Note | See Choice of Data Types for further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Must Support Types | dateTime | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
56. Procedure.recorder | |||||
Definition | 記錄處置/手術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/手術Who recorded the procedure | ||||
Control | 0..1 | ||||
Type | Reference(TW Core Patient, TW Core Practitioner, TW Core PractitionerRole, RelatedPerson, Patient, Practitioner, PractitionerRole) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
58. Procedure.asserter | |||||
Definition | 提出此處置/手術說明的人 Individual who is making the procedure statement. | ||||
Short | 聲稱有此處置/手術的人Person who asserts this procedure | ||||
Control | 0..1 | ||||
Type | Reference(TW Core Patient, RelatedPerson, TW Core Practitioner, TW Core PractitionerRole, Patient, Practitioner, PractitionerRole) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Must Support Types | No must-support rules about the choice of types/profiles | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
60. 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/手術的人員The people who performed the procedure | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
62. Procedure.performer.modifierExtension | |||||
Definition | 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 | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | 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 Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) | ||||
64. Procedure.performer.function | |||||
Definition | 區分執行者在處置/手術中的參與型別,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. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-role (extensible to http://hl7.org/fhir/ValueSet/performer-role )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 A code that identifies the role of a performer of the procedure. | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
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. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
66. Procedure.performer.actor | |||||
Definition | 參與處置/手術的健康照護服務提供者 The practitioner who was involved in the procedure. | ||||
Short | 參照至健康照護服務提供者The reference to the practitioner | ||||
Control | 1..1 | ||||
Type | Reference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, TW Core Patient, RelatedPerson, Device, Practitioner, PractitionerRole, Organization, Patient) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Must Support Types | No must-support rules about the choice of types/profiles | ||||
Summary | true | ||||
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. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
68. Procedure.performer.onBehalfOf | |||||
Definition | 此裝置或健康照護服務提供者所代表的機構 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者所屬機構(Organization)Organization the device or practitioner was acting for | ||||
Control | 0..1 | ||||
Type | Reference(TW Core Organization, Organization) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | 健康照護服務提供者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. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
70. Procedure.location | |||||
Definition | 實際發生處置/手術的地點(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/手術發生的地點(Location)?Where the procedure happened | ||||
Control | 0..1 | ||||
Type | Reference(TW Core Location, Location) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | 將一個處置/手術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. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
72. Procedure.reasonCode | |||||
Definition | 進行此處置/手術的原因代碼。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/手術執行原因代碼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/手術的不同原因,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. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reason (extensible to http://hl7.org/fhir/ValueSet/procedure-reason )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 A code that identifies the reason a procedure is required. | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
74. Procedure.reasonReference | |||||
Definition | 為什麼進行此處置/手術的原因 The justification of why the procedure was performed. | ||||
Short | 執行此處置/手術的原因The justification that the procedure was performed | ||||
Comments | 一個處置/手術有可能成為另一個處置/手術(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/手術的不同原因,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. | ||||
Control | 0..* | ||||
Type | Reference(TW Core Condition, TW Core Observation Laboratory Result, TW Core Procedure, DiagnosticReport, DocumentReference, Condition, Observation, Procedure) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
76. 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。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. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site (extensible to http://hl7.org/fhir/ValueSet/body-site )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 Codes describing anatomical locations. May include laterality. | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
78. Procedure.outcome | |||||
Definition | 處置/手術的結果—它是否解決了當初執行處置/手術所要解決的問題? The outcome of the procedure - did it resolve the reasons for the procedure being performed? | ||||
Short | 處置/手術的結果。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. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcome (extensible to http://hl7.org/fhir/ValueSet/procedure-outcome )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 An outcome of a procedure - whether it was resolved or otherwise. | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
80. 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/手術產生的任何報告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/手術,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. | ||||
Control | 0..* | ||||
Type | Reference(DiagnosticReport, DocumentReference, Composition) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
82. Procedure.complication | |||||
Definition | 在處置/手術過程中,或在處置/手術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/手術本身,而不是任何 「處置/手術後」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/手術後的併發症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. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code (extensible to http://hl7.org/fhir/ValueSet/condition-code )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 Codes describing complications that resulted from a procedure. | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
84. Procedure.complicationDetail | |||||
Definition | 在處置/手術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/手術後發生的病情、問題或診斷A condition that is a result of the procedure | ||||
Control | 0..* | ||||
Type | Reference(TW Core Condition, Condition) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | 這是用來記錄作為處置/手術結果的病情、問題或診斷,而不是作為處置/手術原因的病情、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. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
86. Procedure.followUp | |||||
Definition | 如果該處置/手術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。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. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followup (extensible to http://hl7.org/fhir/ValueSet/procedure-followup )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 Specific follow up required for a procedure e.g. removal of sutures. | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
88. Procedure.note | |||||
Definition | 關於此處置/手術的任何其他註釋和意見 Any other notes and comments about the procedure. | ||||
Short | 關於此處置/手術的附加資訊Additional information about the procedure | ||||
Control | 0..* | ||||
Type | Annotation | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
90. 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/手術的重點部分。 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 | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
92. Procedure.focalDevice.modifierExtension | |||||
Definition | 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 | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | 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 Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) | ||||
94. Procedure.focalDevice.action | |||||
Definition | 處置/手術過程中,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. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHOULD be taken from ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-action (preferred to http://hl7.org/fhir/ValueSet/device-action )鼓勵使用所綁定值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。 A kind of change that happened to the device during the procedure. | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
96. Procedure.focalDevice.manipulated | |||||
Definition | 在處置/手術中被處理(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 | ||||
Control | 1..1 | ||||
Type | Reference(Device) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
98. Procedure.usedReference | |||||
Definition | 指明藥品、裝置和作為處置/手術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/手術中使用的項目/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. | ||||
Control | 0..* | ||||
Type | Reference(Device, Medication, Substance) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | 用於追蹤污染等 Used for tracking contamination, etc. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
100. Procedure.usedCode | |||||
Definition | 指明作為處置/手術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/手術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. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kind (extensible to http://hl7.org/fhir/ValueSet/device-kind )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 Codes describing items used during a procedure. | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-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/手術、內視鏡處置/手術、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/手術可以由醫護人員、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 | ||||
Control | 0..* | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | dom-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,此resource沒有id,它的id在resource被創建後由伺器分配/指定。 | ||||
Control | 0..1 | ||||
Type | id | ||||
Is Modifier | false | ||||
Summary | true | ||||
4. Procedure.meta | |||||
Definition | 關於resource的metadata。這是由基礎建設維護的內容。內容的更改可能並不總是與resource的版本更改相關聯。 | ||||
Short | 此Procedure Resource的metadata | ||||
Control | 0..1 | ||||
Type | Meta | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-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。通常這是對IG所定義之特殊規則及其他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交易夥伴所理解。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IG的參照,此IG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。 | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | true 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 Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-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資料項目(關於xml:lang和html lang屬性之間的關係,見HTML5中的規則)。 | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from CommonLanguages (preferred to http://hl7.org/fhir/ValueSet/languages )人類語言;鼓勵使用CommonLanguages代碼表中的代碼,但不強制一定要使用此代碼表,你也可使用其他代碼表的代碼或單純以文字表示。
| ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Example | <br/><b>Value</b>:zh-TW | ||||
Invariants | ele-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定義有哪些內容應該在敘述中表示,以確保臨床安全。 | ||||
Short | Procedure 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。有時resource可能只有文字表述,很少或沒有額外的結構化資料(只要滿足所有minOccurs=1的資料項目)。這可能出現在舊系統的資料,當資訊以 「文字表述區塊(text blob) 」的形式被取得,或者文字表述是原始輸入或說明,而編碼資訊稍後再添加。 | ||||
Control | 0..1 | ||||
Type | Narrative | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | narrative, html, xhtml, display | ||||
Invariants | ele-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,因為一旦失去識別,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,但不應該有安全標號(security labels)。 | ||||
Control | 0..* | ||||
Type | Resource | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | inline resources, anonymous resources, contained resources | ||||
14. Procedure.extension | |||||
Definition | 可用於表示不屬於此resource基本定義的額外資訊。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,必須(SHALL) 滿足一系列要求。 | ||||
Short | 擴充的資料項目 | ||||
Comments | 任何應用程式、專案或標準使用擴充時,都不應該帶有任何負面的聯想。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。 | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
16. Procedure.modifierExtension | |||||
Definition | 可以用來表示不屬於此resource的基本定義的額外資訊,並修改包含它所內嵌(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的資訊。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。雖然任何實作者都可以定義一個擴充,但在定義擴充時 必須(SHALL) 滿足一組要求。處理resource的應用程式需要檢查修飾用的擴充資料項目。 | ||||
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 | 任何應用程式、專案或標準使用擴充時,都不應該帶有任何負面的聯想。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。 | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them | ||||
Summary | false | ||||
Requirements | 修飾用的資料項目擴充允許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。這樣做有助於促進可互操作性,因為無需禁止實作者使用擴充,想要瞭解更多資訊,請參見[修飾用的資料項目擴充之定義](http://hl7.org/fhir/R4/extensibility.html#modifierExtension)。 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
18. Procedure.identifier | |||||
Definition | 由執行者或其他系統指定給此處置/手術的業務用識別碼,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/手術的外部識別碼 | ||||
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。 | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 0..* | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | 允許識別各參與系統所知的此處置/手術資訊,並在各伺服器之間保持一致的方式。 | ||||
Invariants | ele-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/手術全部或部分遵守的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 | ||||
Control | 0..* | ||||
Type | canonical(PlanDefinition, ActivityDefinition, Measure, OperationDefinition, Questionnaire) | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-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/手術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。 | ||||
Control | 0..* | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-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/手術請求的細節。 | ||||
Short | 此Procedure是基於什麼而履行 | ||||
Control | 0..* | ||||
Type | Reference(CarePlan, ServiceRequest) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Alternate Names | fulfills | ||||
Invariants | ele-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/手術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/手術的一部分(MedicationAdministration.partOf = Procedure)。例如:為靜脈給藥插入靜脈口的處置/手術是給藥的一部分(Procedure.partOf = MedicationAdministration)。 | ||||
Control | 0..* | ||||
Type | Reference(TW Core Procedure, TW Core Observation Laboratory Result, MedicationAdministration) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Alternate Names | container | ||||
Invariants | ele-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/手術當前狀態的代碼。一般來說,它是進行中或完成的狀態。 | ||||
Short | preparation | 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/手術的當前狀態,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。 | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from EventStatus (required to http://hl7.org/fhir/ValueSet/event-status|4.0.1 )應填入所綁定值集中的其中一個代碼 | ||||
Type | code | ||||
Is Modifier | true 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 Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-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。 | ||||
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/手術的原因是在reasonCode中說明,而不是在這裡。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from ProcedureNotPerformedReason(SNOMED-CT) (extensible to http://hl7.org/fhir/ValueSet/procedure-not-performed-reason )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Alternate Names | Suspended Reason, Cancelled Reason | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
32. Procedure.category | |||||
Definition | 對處置/手術進行分類的代碼(例如:「手術處置/手術」)。主要為了搜尋、排序和顯示時使用。 | ||||
Short | 處置/手術的分類。 | ||||
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. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from ProcedureCategoryCodes(SNOMEDCT) (extensible to http://hl7.org/fhir/ValueSet/procedure-category )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-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/手術。如果不能對處置/手術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/手術的識別碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 | ||||
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. | ||||
Control | 1..1 This element is affected by the following invariants: ele-1 | ||||
Binding | For example codes, see ProcedureCodes(SNOMEDCT) (example to http://hl7.org/fhir/ValueSet/procedure-code )A code to identify a specific procedure . | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Requirements | 0..1主要僅用於解釋敘述性的resource。 | ||||
Alternate Names | type | ||||
Invariants | ele-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。 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
38. Procedure.code.extension | |||||
Definition | 擴充的資料項目 | ||||
Short | 擴充的資料項目 | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on Procedure.code.extension . The slices are unordered and Open, and can be differentiated using the following discriminators: | ||||
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。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 | ||||
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。 | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | 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 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
Slicing | This element introduces a set of slices on Procedure.code.coding . The slices are unordered and Open, and can be differentiated using the following discriminators: | ||||
42. Procedure.code.coding:icd10-pcs-2021 | |||||
Slice Name | icd10-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(NHI)維護之2021年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 | ||||
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。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from 臺灣健保署2021年中文版ICD-10-PCS值集 (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw )處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | 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 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
44. Procedure.code.coding:icd10-pcs-2014 | |||||
Slice Name | icd10-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(NHI)維護之2014年中文版ICD-10-PCS代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 | ||||
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。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from 臺灣健保署2014年中文版ICD-10-PCS值集 (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2014-tw )處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | 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 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
46. Procedure.code.coding:icd9-cm-2001 | |||||
Slice Name | icd9-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。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from 臺灣健保署2001年中文版ICD-9-CM值集 (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw ) | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Requirements | 允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
48. Procedure.code.coding:medical-service-payment | |||||
Slice Name | medical-service-payment | ||||
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(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。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from 臺灣衛福部統計處藥品使用頻率值集 (required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/medication-frequency-tw )處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | 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 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
50. Procedure.code.coding:sct-procedures | |||||
Slice Name | sct-procedures | ||||
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/手術代碼,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。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from ProcedureCodes(SNOMEDCT) (required to http://hl7.org/fhir/ValueSet/procedure-code )處置/手術的識別;應填入所綁定值集中的其中一個代碼。 | ||||
Type | Coding(TW Coding) | ||||
Is Modifier | false | ||||
Must Support | 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 | ||||
Invariants | ele-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。 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
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。 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
54. Procedure.subject | |||||
Definition | 進行處置/手術的病人、動物或實體集合(例如:特定的一群人)。 | ||||
Short | 處置/手術服務的對象 | ||||
Control | 1..1 | ||||
Type | Reference(TW Core Patient) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Alternate Names | patient | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
56. Procedure.encounter | |||||
Definition | 此「處置/手術(Procedure)」記載在哪次的「就醫(Encounter)」紀錄或者與此處置/手術紀錄密切相關的「就醫(Encounter)」紀錄 | ||||
Short | 就醫(Encounter)紀錄作為處置/手術的一部分 | ||||
Comments | 通常是此處置/手術發生的就醫事件(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/手術紀錄相關的就醫事件。 | ||||
Control | 0..1 | ||||
Type | Reference(TW Core Encounter) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-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/手術的估計或實際日期、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/手術,也允許捕捉處置/手術的執行時間長度。 | ||||
Short | 此處置/手術何時執行的? | ||||
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/手術被報告為過去的處置/手術,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/手術可能有更精確的UTC時間戳記和時區。 | ||||
Control | 0..1 | ||||
Type | Choice of: dateTime, Period, string, Age, Range | ||||
[x] Note | See Choice of Data Types for further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Must Support Types | dateTime | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
60. Procedure.recorder | |||||
Definition | 記錄處置/手術內容並對其內容負責的個人 | ||||
Short | 誰記錄此處置/手術 | ||||
Control | 0..1 | ||||
Type | Reference(TW Core Patient, TW Core Practitioner, TW Core PractitionerRole, RelatedPerson) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-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/手術說明的人 | ||||
Short | 聲稱有此處置/手術的人 | ||||
Control | 0..1 | ||||
Type | Reference(TW Core Patient, RelatedPerson, TW Core Practitioner, TW Core PractitionerRole) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Must Support Types | No must-support rules about the choice of types/profiles | ||||
Summary | true | ||||
Invariants | ele-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/手術的人員 | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
66. Procedure.performer.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
68. Procedure.performer.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
70. Procedure.performer.modifierExtension | |||||
Definition | 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 | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | 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 Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
72. Procedure.performer.function | |||||
Definition | 區分執行者在處置/手術中的參與型別,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. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from ProcedurePerformerRoleCodes (extensible to http://hl7.org/fhir/ValueSet/performer-role )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Requirements | 允許針對不同執行者的參與型別進行澄清以消除歧義 | ||||
Invariants | ele-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/手術的健康照護服務提供者 | ||||
Short | 參照至健康照護服務提供者 | ||||
Control | 1..1 | ||||
Type | Reference(TW Core Practitioner, TW Core PractitionerRole, TW Core Organization, TW Core Patient, RelatedPerson, Device) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Must Support Types | No must-support rules about the choice of types/profiles | ||||
Summary | true | ||||
Requirements | 一個參照至裝置(Device)的使用案例,例如:心律調整器。 | ||||
Invariants | ele-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者所代表的機構 | ||||
Short | 此裝置(Device)或健康照護服務提供者所屬機構(Organization) | ||||
Control | 0..1 | ||||
Type | Reference(TW Core Organization) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | 健康照護服務提供者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。 | ||||
Invariants | ele-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/手術的地點(Location)。例如:新生兒在家裡出生、在餐廳做氣管切開術。 | ||||
Short | 處置/手術發生的地點(Location)? | ||||
Control | 0..1 | ||||
Type | Reference(TW Core Location) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | 將一個處置/手術與可能保存紀錄的地點(Location)聯繫起來 | ||||
Invariants | ele-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/手術的原因代碼。這可能是某種型別的編碼,也可能只是文字表述。 | ||||
Short | 處置/手術執行原因代碼 | ||||
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/手術的不同原因,則兩者都可以使用。 | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from ProcedureReasonCodes (extensible to http://hl7.org/fhir/ValueSet/procedure-reason )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-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/手術的原因 | ||||
Short | 執行此處置/手術的原因 | ||||
Comments | 一個處置/手術有可能成為另一個處置/手術(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/手術的不同原因,則兩者都可以使用。 | ||||
Control | 0..* | ||||
Type | Reference(TW Core Condition, TW Core Observation Laboratory Result, TW Core Procedure, DiagnosticReport, DocumentReference) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-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。 | ||||
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)。 | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from SNOMEDCTBodyStructures (extensible to http://hl7.org/fhir/ValueSet/body-site )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
86. Procedure.outcome | |||||
Definition | 處置/手術的結果—它是否解決了當初執行處置/手術所要解決的問題? | ||||
Short | 處置/手術的結果。 | ||||
Comments | 如果結果只包含敘述性文字,可用CodeableConcept.text來說明。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from ProcedureOutcomeCodes(SNOMEDCT) (extensible to http://hl7.org/fhir/ValueSet/procedure-outcome )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-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/手術產生的任何報告 | ||||
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/手術,會產生一些解剖病理報告。 | ||||
Control | 0..* | ||||
Type | Reference(DiagnosticReport, DocumentReference, Composition) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
90. Procedure.complication | |||||
Definition | 在處置/手術過程中,或在處置/手術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/手術本身,而不是任何 「處置/手術後」的問題。 | ||||
Short | 處置/手術後的併發症 | ||||
Comments | 如果併發症僅由敘述性文字表達,可用CodeableConcept.text來說明。 | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from Condition/Problem/DiagnosisCodes (extensible to http://hl7.org/fhir/ValueSet/condition-code )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
92. Procedure.complicationDetail | |||||
Definition | 在處置/手術過程中或在執行結束後立即發生的任何併發症 | ||||
Short | 處置/手術後發生的病情、問題或診斷 | ||||
Control | 0..* | ||||
Type | Reference(TW Core Condition) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | 這是用來記錄作為處置/手術結果的病情、問題或診斷,而不是作為處置/手術原因的病情、問題或診斷。 | ||||
Invariants | ele-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/手術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。 | ||||
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. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from ProcedureFollowUpCodes(SNOMEDCT) (extensible to http://hl7.org/fhir/ValueSet/procedure-followup )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-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/手術的任何其他註釋和意見 | ||||
Short | 關於此處置/手術的附加資訊 | ||||
Control | 0..* | ||||
Type | Annotation | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-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/手術的重點部分。 | ||||
Short | 處理、植入的或移除的裝置 | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
100. Procedure.focalDevice.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
102. Procedure.focalDevice.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
104. Procedure.focalDevice.modifierExtension | |||||
Definition | 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 | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | 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 Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
106. Procedure.focalDevice.action | |||||
Definition | 處置/手術過程中,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. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHOULD be taken from ProcedureDeviceActionCodes (preferred to http://hl7.org/fhir/ValueSet/device-action )鼓勵使用所綁定值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
108. Procedure.focalDevice.manipulated | |||||
Definition | 在處置/手術中被處理(改變)的裝置 | ||||
Short | 被改變的裝置 | ||||
Control | 1..1 | ||||
Type | Reference(Device) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-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/手術一部分的任何其他物質 | ||||
Short | 處置/手術中使用的項目/物品 | ||||
Comments | 對於實際植入或取出的裝置,使用Procedure.device。 | ||||
Control | 0..* | ||||
Type | Reference(Device, Medication, Substance) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | 用於追蹤污染等 | ||||
Invariants | ele-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/手術的一部分而使用的編碼項目 | ||||
Short | 處置/手術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。 | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from FHIRDeviceTypes (extensible to http://hl7.org/fhir/ValueSet/device-kind )應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) |