This page is part of the 臺灣核心實作指引(TW Core IG) (v0.3.1: 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 2024-10-22 |
Definitions for the AllergyIntolerance-twcore resource profile.
Guidance on how to interpret the contents of this table can be found here
0. AllergyIntolerance | |||||
Definition | 可能對個人產生有害或不希望的生理反應的風險,這種反應是與暴露於某種物質相關的,並且對每個人來說都是獨特的。 | ||||
Short | 過敏或不耐症(通常指:對某種物質有不良反應的風險) | ||||
Comments | 物質包括但不限於:適合個人的劑量正確使用的治療性物質、食品、來自植物或動物的材質、或昆蟲叮咬所釋放的毒液。 | ||||
2. AllergyIntolerance.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AllergyIntolerance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. AllergyIntolerance.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AllergyIntolerance Resource的metadata | ||||
6. AllergyIntolerance.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. AllergyIntolerance.language | |||||
Definition | 編寫此resource的語言 | ||||
Short | 用以表述AllergyIntolerance 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. AllergyIntolerance.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 | AllergyIntolerance 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. AllergyIntolerance.identifier | |||||
Definition | 由執行者或其他系統指定給這個AllergyIntolerance的業務識別碼,隨著resource更新和從伺服器到伺服器的傳送,這些識別碼保持不變。 | ||||
Short | 過敏或不耐症之外部識別碼 | ||||
Comments | 這是過敏或不耐症紀錄的業務識別碼,不是一個 resource 識別碼(請參見討論小節)。最好的做法是該識別碼只出現在單一個resource實例上,但是實務上有時會要求具有相同識別碼的多個resource實例共存,這些 resources 實例甚至可能屬於不同的resource類型。例如:多個 Patient及一個Person resource實例可能共用同一個社會保險碼(此處是指美國民眾會有唯一可識別的社會保險碼)。 | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Requirements | 允許各參與系統按照一致的方式,在不同伺服器之間確認並識別 AllergyIntolerance。 | ||||
14. AllergyIntolerance.clinicalStatus | |||||
Definition | 過敏或不耐症的臨床狀態 | ||||
Short | active | inactive | resolved ,過敏或不耐症的臨床狀態。 | ||||
Comments | 如果 clincalStatus 缺少資料,請查閱討論小節。其資料類型是CodeableConcept,這是因為clinicalStatus涉及到一些臨床判斷,可能需要的具體性超過FHIR值集所要求的範圍。例如:SNOMED代碼可能提供額外的的具體性。 | ||||
Binding | The codes SHALL be taken from AllergyIntoleranceClinicalStatusCodes (required to http://hl7.org/fhir/ValueSet/allergyintolerance-clinical|4.0.1 )應填入所綁定值集中的其中一個代碼。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Must Support | true | ||||
16. AllergyIntolerance.verificationStatus | |||||
Definition | 一個人對某已識別物質(包括醫藥產品)產生反應的可能性或風險有多確定的陳述 | ||||
Short | unconfirmed | confirmed | refuted | entered-in-error ,一個人對特定物質產生反應的可能性或風險有多確定的陳述。 | ||||
Binding | The codes SHALL be taken from AllergyIntoleranceVerificationStatusCodes (required to http://hl7.org/fhir/ValueSet/allergyintolerance-verification|4.0.1 )應填入所綁定值集中的其中一個代碼。 | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Must Support | true | ||||
18. AllergyIntolerance.type | |||||
Definition | 為什麼某人對特定物質(如藥物或食物)會有反應的生理根本原因 | ||||
Short | allergy | intolerance - 根本原因或運作機制(如果知道)。 | ||||
Comments | 過敏反應通常是我們身體免疫系統的一種反應,它被認為可能預示著未來有更嚴重的健康風險。然而,現代醫學研究顯示,有些過去被認為是免疫反應的情況實際上可能並不是,但仍然可能對生命造成危害。有時候,醫生難以確定一個特定反應的機制是免疫相關還是非免疫相關的。此外,「過敏」這個詞經常被廣泛地使用,並且可能與「不耐症」這個詞的使用有所重疊。在實際應用中,這兩個概念的界限可能不太清晰或不容易理解。儘管如此,醫療紀錄中仍然包含了有關過敏反應的資訊,因為許多既有的醫療系統都已經收集了這些資料。免疫學檢測可以提供一些證據幫助確定反應的基礎和引起反應的物質,但這些檢測並不總是百分之百準確,無法100%確定對特定物質的敏感性。如果不清楚反應是否由過敏引起還是由不耐症引起,那麼在醫療紀錄中最好不要具體指定反應的類型,即可忽略及不填寫此資料項目。 | ||||
Binding | The codes SHALL be taken from AllergyIntoleranceType (required to http://hl7.org/fhir/ValueSet/allergy-intolerance-type|4.0.1 )確定反應風險的基本生理機制;應填入所綁定值集中的其中一個代碼。 | ||||
20. AllergyIntolerance.category | |||||
Definition | 被識別的物質的類別 | ||||
Comments | 這個資料資料項目被包括在內,因為它目前正在一些臨床系統中被採集。這個資料可以從使用編碼系統的物質中得到,在這種情況下實際上是多餘的。當按類別查詢時,考慮沒有類別的AllergyIntoleranceresource的影響。例如,當查詢類別=藥品時,沒有類別價值的藥品過敏將不會被返回。關於如何用:缺失修飾符查詢類別以獲得沒有類別的過敏,請參考查詢的更多資訊。此外,類別應謹慎使用,因為類別可能是基於寄件者的主觀因素。 | ||||
Binding | The codes SHALL be taken from AllergyIntoleranceCategory (required to http://hl7.org/fhir/ValueSet/allergy-intolerance-category|4.0.1 )確定的物質的類別;應填入所綁定值集中的其中一個代碼。 | ||||
22. AllergyIntolerance.criticality | |||||
Definition | 對已識別物質的反應的潛在臨床危害程度,或稱嚴重性估計。 | ||||
Comments | 對於任何對可能引發不良反應的傾向,預設的危險程度應該設定為「低風險」,這表示 至少相對不建議 有意或自願接觸這種物質。如果醫生識別出對更嚴重或可能危及生命的反應,如過敏性休克的傾向,則將其標記為「高風險」,這表示 絕對不建議 有意或自願接觸這種物質。如果缺少這個資料項目,則表示危險程度未知(雖然在其他地方可能已知)。取得疾病層次(condition level)危險性(criticality))的現有系統實際上是在表示危險性的概念,而在反應層次(reaction level)記錄的嚴重性(severity)表示真正的反應嚴重性。現有系統同時記錄疾病危險性和反應嚴重性,可能使用「嚴重性(severity)」一詞來表示兩者。危險性是未來可能出現的最糟糕情況(即不考慮具體情境),而嚴重性則依賴於特定情境。 | ||||
Binding | The codes SHALL be taken from AllergyIntoleranceCriticality (required to http://hl7.org/fhir/ValueSet/allergy-intolerance-criticality|4.0.1 )對已識別物質的反應的潛在臨床危害程度,或稱嚴重性估計;應填入所綁定值集中的其中一個代碼。 | ||||
24. AllergyIntolerance.code | |||||
Definition | 此資料項目是用來代碼化表示有關過敏或不耐症的資訊。它可以表示對某種物質或藥物產品引發不良反應風險的代碼(例如:「乳膠」),也可以表示有關過敏或不耐症的代碼(例如:「乳膠過敏」),或者是表示對特定物質或類別的否定或排除情況的代碼(例如:「無乳膠過敏」),還可以表示一般性的否定性聲明(例如:「無已知過敏」,「無已知藥品過敏」)。需要注意的是:特定反應的物質可能不同於被認為引發風險的物質,但它們之間必須是一致的,在處理這些資訊時,只處理「code」而忽略「reaction.substance」在臨床上必須在是安全的。如果接收系統無法確認AllergyIntolerance.reaction.substance是否符合AllergyIntolerance.code的語義範圍,則應該忽略AllergyIntolerance.reaction.substance。 | ||||
Short | 表明此過敏或不耐症的代碼 | ||||
Comments | 建議在填寫過敏或不耐症相關資料時,儘量使用專業術語。常用的專門術語包括RxNorm、SNOMED CT、DM+D、NDFRT、ICD-9、IDC-10、UNII和ATC等。如果找不到合適的專業術語,則可以用文字表述。文字表述還可以提供更多詳細資訊。 當我們為「code」資料項目指定特定物質或產品代碼時,通常意味著該病人對這種物質或產品有過敏或不耐受反應。在SNOMED CT的過敏模型中,這些物質或產品被視為「過敏物質(Causative agent)」。 另外,還有一個名為「substanceExposureRisk」的擴充資料項目,它比「code」資料項目提供更多靈活性,可以用來描述對特定物質或產品的過敏或不耐受反應,無論是正面還是負面。這個擴充資料項目特別有用於表達「沒有已知過敏」或「沒有不良反應風險」的情況,即使對於那些沒有預先確定「無過敏」概念的物質或產品也適用。如果使用了「substanceExposureRisk」擴充資料項目,則應該省略AllergyIntolerance.code資料項目。 | ||||
Control | 1..? | ||||
Binding | Unless not suitable, these codes SHALL be taken from AllergyIntoleranceSubstance/Product,ConditionAndNegationCodes (extensible to http://hl7.org/fhir/ValueSet/allergyintolerance-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) | ||||
Must Support | true | ||||
26. AllergyIntolerance.patient | |||||
Definition | 患有過敏或不耐症的病人 | ||||
Short | 誰有此過敏或不耐受? | ||||
Type | Reference(TW Core Patient) | ||||
Must Support | true | ||||
28. AllergyIntolerance.encounter | |||||
Definition | 過敏症或不耐症被確認的就醫事件(Encounter) | ||||
Short | 過敏或不耐症被確認時的就醫事件(Encounter) | ||||
Type | Reference(TW Core Encounter) | ||||
30. AllergyIntolerance.onset[x] | |||||
Definition | 過敏或不耐症被識別的估計或實際日期、日期時間或年齡。 | ||||
Short | 過敏或不耐症被識別的時間 | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
32. AllergyIntolerance.recordedDate | |||||
Definition | recordedDate指的是這個特定的過敏不耐症紀錄在系統中建立的日期,通常是由系統產生的日期。 | ||||
Short | resource實例的第一個版本被記錄的日期 | ||||
Must Support | true | ||||
34. AllergyIntolerance.recorder | |||||
Definition | 記錄此紀錄並對其內容負責的個人 | ||||
Short | 誰記錄了過敏或不耐受 | ||||
Type | Reference(TW Core Practitioner, TW Core PractitionerRole, TW Core Patient, TW Core RelatedPerson) | ||||
Must Support | true | ||||
Must Support Types | No must-support rules about the choice of types/profiles | ||||
36. AllergyIntolerance.asserter | |||||
Definition | 有關過敏紀錄的資訊來源 | ||||
Short | 關於過敏的資訊來源 | ||||
Comments | 記錄者要對內容負有責任,但可以參照他們獲得資訊的來源。 | ||||
Type | Reference(TW Core Patient, TW Core RelatedPerson, TW Core Practitioner, TW Core PractitionerRole) | ||||
38. AllergyIntolerance.lastOccurrence | |||||
Definition | 表示最後已知的過敏反應事件發生的日期和/或時間。 | ||||
Short | 最後一次已知反應發生的日期(/時間) | ||||
Comments | 這個日期可能會與某個反應開始日期重複。如果需要以文字表述最後發生的日期,例如:「在童年時」或「10年前」,應該使用 Comment 資料項目。 | ||||
40. AllergyIntolerance.note | |||||
Definition | 有關不良反應的可能性,這些資訊是未被記錄在其他資料項目中的補充敘述。 | ||||
Short | 其他欄位中沒有記錄的額外文字陳述 | ||||
Comments | 例如:包括標記為「高風險」的原因,以及與將來接觸或使用該物質相關的指示,比如在重症照護病房內使用或在使用時需要皮質類固醇保護。這些註釋應該與過敏或不耐症作為一般狀況有關,而不是特定事件。對於特定事件的描述和註釋,請使用 AllergyIntolerance.event.description 和 AllergyIntolerance.event.notes。 | ||||
Must Support | true | ||||
42. AllergyIntolerance.reaction | |||||
Definition | 關於每次接觸特定物質所引起的不良反應事件的細節 | ||||
Short | 暴露於此過敏或不耐症物質的不良反應 | ||||
Must Support | true | ||||
44. AllergyIntolerance.reaction.substance | |||||
Definition | 確定與不良反應事件有關的特定物質(或藥品)。注意:對於特定反應而言,所涉及的物質可能與被認為是風險原因的物質不同,但它必須與之一致。例如:它可能是一種更具體的物質(例如:品牌藥物)或包含被確認的物質的複合產品。在臨床上,僅處理「code」而忽略「reaction.substance」必須是安全的。如果接收系統無法確定 AllergyIntolerance.reaction.substance 是否在 AllergyIntolerance.code 的語義範圍內,則接收系統應忽略 AllergyIntolerance.reaction.substance。 | ||||
Short | 被認為是事件原因的特定物質或醫藥產品 | ||||
Comments | 表現形式可以用一個詞、短語或簡短的描述來表達。例如:噁心、皮疹或無反應。在可能的情況下,最好用專門術語對表現形式進行編碼。這裡輸入的值可作為不良反應清單的一部分顯示在應用螢幕上,正如英國國家醫療服務體系CUI 指南中所建議的那樣,常用的專門術語包括,但不限於SNOMED CT或ICD10。 | ||||
Binding | Unless not suitable, these codes SHALL be taken from SubstanceCode (extensible to http://hl7.org/fhir/ValueSet/substance-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) | ||||
46. AllergyIntolerance.reaction.manifestation | |||||
Definition | 觀察到的或與不良反應事件相關的臨床症狀和/或體徵 | ||||
Short | 與此事件相關的臨床症狀/體徵 | ||||
Comments | 表現形式可以用一個詞、短語或簡短的描述來表達。例如:噁心、皮疹或無反應。在可能的情況下,最好用術語對表現形式進行編碼。這裡輸入的數值可作為不良反應清單的一部分顯示在應用螢幕上,正如英國國家醫療服務體系CUI指南中所建議的那樣。常用的術語包括,但不限於SNOMED CT或ICD10。 | ||||
Binding | Unless not suitable, these codes SHALL be taken from SNOMEDCTClinicalFindings (extensible to http://hl7.org/fhir/ValueSet/clinical-findings )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 | ||||
48. AllergyIntolerance.reaction.description | |||||
Definition | 關於整個反應的文字描述,如果必要則包括表現形式的細節。 | ||||
Short | 對整個活動的描述 | ||||
Comments | 使用描述來提供發生反應的特定事件的任何細節,如情況、反應細節、之前/之後發生了什麼。與事件有關的資訊,但不描述特定的照護應在comment資料項目中記錄。例如:病人在四歲時因鏈球菌感染被注射青黴素,隨後出現嚴重的蕁麻疹。 | ||||
50. AllergyIntolerance.reaction.onset | |||||
Definition | 記錄反應開始的日期和/或時間 | ||||
Short | 症狀顯現的日期(/時間) | ||||
52. AllergyIntolerance.reaction.severity | |||||
Definition | 對整個反應事件的臨床評估,可能會考慮多個不同的表現,以確定反應的嚴重程度。 | ||||
Short | mild | moderate | severe | ||||
Comments | 這種評估是非常主觀的。可能有一些特定的實務領域已經應用了客觀的評分標準,客觀的評分標準可以作為擴充資料項目包含在這個模型中。 | ||||
Binding | The codes SHALL be taken from AllergyIntoleranceSeverity (required to http://hl7.org/fhir/ValueSet/reaction-event-severity|4.0.1 )整個事件的程度,應填入所綁定值集中的其中一個代碼。 | ||||
54. AllergyIntolerance.reaction.exposureRoute | |||||
Definition | 確認此對象是透過哪種途徑接觸到該物質 | ||||
Short | 此對象如何接觸到該物質 | ||||
Comments | 應盡可能使用專門術語對接觸途徑進行編碼。 | ||||
Binding | Unless not suitable, these codes SHALL be taken from SNOMEDCTRouteCodes (extensible to http://hl7.org/fhir/ValueSet/route-codes )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) | ||||
56. AllergyIntolerance.reaction.note | |||||
Definition | 其他關於不良反應事件的文字表述,這些資訊未在其他資料項目中記錄。 | ||||
Short | 其他資料項目未記錄之關於事件的文字表述 | ||||
Comments | 使用此資料項目記錄與特定事件間接相關的資訊,但在其他資料項目未記錄的資訊。例如:如果臨床紀錄不再可用,則可根據病人母親提供的資訊來紀錄,儘管病人的母親已經過世。 |
Guidance on how to interpret the contents of this table can be found here
0. AllergyIntolerance | |||||
Definition | 可能對個人產生有害或不希望的生理反應的風險,這種反應是與暴露於某種物質相關的,並且對每個人來說都是獨特的。 Risk of harmful or undesirable, physiological response which is unique to an individual and associated with exposure to a substance. | ||||
Short | 過敏或不耐症(通常指:對某種物質有不良反應的風險)Allergy or Intolerance (generally: Risk of adverse reaction to a substance) | ||||
Comments | 物質包括但不限於:適合個人的劑量正確使用的治療性物質、食品、來自植物或動物的材質、或昆蟲叮咬所釋放的毒液。 Substances include, but are not limited to: a therapeutic substance administered correctly at an appropriate dosage for the individual; food; material derived from plants or animals; or venom from insect stings. | ||||
Control | 0..* | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | Allergy, Intolerance, Adverse Reaction | ||||
Invariants | ait-1: AllergyIntolerance.clinicalStatus SHALL be present if verificationStatus is not entered-in-error. (verificationStatus.coding.where(system = 'http://terminology.hl7.org/CodeSystem/allergyintolerance-verification' and code = 'entered-in-error').exists() or clinicalStatus.exists() )ait-2: AllergyIntolerance.clinicalStatus SHALL NOT be present if verification Status is entered-in-error ( verificationStatus.coding.where(system = 'http://terminology.hl7.org/CodeSystem/allergyintolerance-verification' and code = 'entered-in-error').empty() or clinicalStatus.empty() )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()) ait-1: AllergyIntolerance.clinicalStatus SHALL be present if verificationStatus is not entered-in-error. (verificationStatus.coding.where(system = 'http://terminology.hl7.org/CodeSystem/allergyintolerance-verification' and code = 'entered-in-error').exists() or clinicalStatus.exists()) ait-2: AllergyIntolerance.clinicalStatus SHALL NOT be present if verification Status is entered-in-error (verificationStatus.coding.where(system = 'http://terminology.hl7.org/CodeSystem/allergyintolerance-verification' and code = 'entered-in-error').empty() or clinicalStatus.empty()) | ||||
2. AllergyIntolerance.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AllergyIntolerance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. AllergyIntolerance.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AllergyIntolerance 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. AllergyIntolerance.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. AllergyIntolerance.language | |||||
Definition | 編寫此resource的語言 The base language in which the resource is written. | ||||
Short | 用以表述AllergyIntolerance 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. AllergyIntolerance.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 | AllergyIntolerance 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. AllergyIntolerance.modifierExtension | |||||
Definition | 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 | Extensions that cannot be ignored | ||||
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 resource that contains them | ||||
Summary | false | ||||
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 | ||||
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()) | ||||
14. AllergyIntolerance.identifier | |||||
Definition | 由執行者或其他系統指定給這個AllergyIntolerance的業務識別碼,隨著resource更新和從伺服器到伺服器的傳送,這些識別碼保持不變。 Business identifiers assigned to this AllergyIntolerance by the performer or other systems which remain constant as the resource is updated and propagates from server to server. | ||||
Short | 過敏或不耐症之外部識別碼External ids for this item | ||||
Comments | 這是過敏或不耐症紀錄的業務識別碼,不是一個 resource 識別碼(請參見討論小節)。最好的做法是該識別碼只出現在單一個resource實例上,但是實務上有時會要求具有相同識別碼的多個resource實例共存,這些 resources 實例甚至可能屬於不同的resource類型。例如:多個 Patient及一個Person resource實例可能共用同一個社會保險碼(此處是指美國民眾會有唯一可識別的社會保險碼)。 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 a Person resource instance 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 | 允許各參與系統按照一致的方式,在不同伺服器之間確認並識別 AllergyIntolerance。 Allows identification of the AllergyIntolerance 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())) | ||||
16. AllergyIntolerance.clinicalStatus | |||||
Definition | 過敏或不耐症的臨床狀態 The clinical status of the allergy or intolerance. | ||||
Short | active | inactive | resolved ,過敏或不耐症的臨床狀態。 | ||||
Comments | 如果 clincalStatus 缺少資料,請查閱討論小節。其資料類型是CodeableConcept,這是因為clinicalStatus涉及到一些臨床判斷,可能需要的具體性超過FHIR值集所要求的範圍。例如:SNOMED代碼可能提供額外的的具體性。 Refer to discussion if clincalStatus is missing data. The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1, ait-1, ait-2 | ||||
Binding | The codes SHALL be taken from AllergyIntoleranceClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/allergyintolerance-clinical|4.0.1 (required to http://hl7.org/fhir/ValueSet/allergyintolerance-clinical|4.0.1 )應填入所綁定值集中的其中一個代碼。 The clinical status of the allergy or intolerance. | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | falsetrue because This element is labeled as a modifier because the status contains the codes inactive and resolved that mark the AllergyIntolerance as no longer active. | ||||
Must Support | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
18. AllergyIntolerance.verificationStatus | |||||
Definition | 一個人對某已識別物質(包括醫藥產品)產生反應的可能性或風險有多確定的陳述 Assertion about certainty associated with the propensity, or potential risk, of a reaction to the identified substance (including pharmaceutical product). | ||||
Short | unconfirmed | confirmed | refuted | entered-in-error ,一個人對特定物質產生反應的可能性或風險有多確定的陳述。 | ||||
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. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1, ait-1, ait-2 | ||||
Binding | The codes SHALL be taken from AllergyIntoleranceVerificationStatusCodeshttp://hl7.org/fhir/ValueSet/allergyintolerance-verification|4.0.1 (required to http://hl7.org/fhir/ValueSet/allergyintolerance-verification|4.0.1 )應填入所綁定值集中的其中一個代碼。 Assertion about certainty associated with a propensity, or potential risk, of a reaction to the identified substance. | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | falsetrue because This element is labeled as a modifier because the status contains the codes refuted and entered-in-error that mark the AllergyIntolerance as not currently valid. | ||||
Must Support | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
20. AllergyIntolerance.type | |||||
Definition | 為什麼某人對特定物質(如藥物或食物)會有反應的生理根本原因 Identification of the underlying physiological mechanism for the reaction risk. | ||||
Short | allergy | intolerance - 根本原因或運作機制(如果知道)。allergy | intolerance - Underlying mechanism (if known) | ||||
Comments | 過敏反應通常是我們身體免疫系統的一種反應,它被認為可能預示著未來有更嚴重的健康風險。然而,現代醫學研究顯示,有些過去被認為是免疫反應的情況實際上可能並不是,但仍然可能對生命造成危害。有時候,醫生難以確定一個特定反應的機制是免疫相關還是非免疫相關的。此外,「過敏」這個詞經常被廣泛地使用,並且可能與「不耐症」這個詞的使用有所重疊。在實際應用中,這兩個概念的界限可能不太清晰或不容易理解。儘管如此,醫療紀錄中仍然包含了有關過敏反應的資訊,因為許多既有的醫療系統都已經收集了這些資料。免疫學檢測可以提供一些證據幫助確定反應的基礎和引起反應的物質,但這些檢測並不總是百分之百準確,無法100%確定對特定物質的敏感性。如果不清楚反應是否由過敏引起還是由不耐症引起,那麼在醫療紀錄中最好不要具體指定反應的類型,即可忽略及不填寫此資料項目。 Allergic (typically immune-mediated) reactions have been traditionally regarded as an indicator for potential escalation to significant future risk. Contemporary knowledge suggests that some reactions previously thought to be immune-mediated are, in fact, non-immune, but in some cases can still pose a life threatening risk. It is acknowledged that many clinicians might not be in a position to distinguish the mechanism of a particular reaction. Often the term "allergy" is used rather generically and may overlap with the use of "intolerance" - in practice the boundaries between these two concepts might not be well-defined or understood. This data element is included nevertheless, because many legacy systems have captured this attribute. Immunologic testing may provide supporting evidence for the basis of the reaction and the causative substance, but no tests are 100% sensitive or specific for sensitivity to a particular substance. If, as is commonly the case, it is unclear whether the reaction is due to an allergy or an intolerance, then the type element should be omitted from the resource. | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from AllergyIntoleranceTypehttp://hl7.org/fhir/ValueSet/allergy-intolerance-type|4.0.1 (required to http://hl7.org/fhir/ValueSet/allergy-intolerance-type|4.0.1 )確定反應風險的基本生理機制;應填入所綁定值集中的其中一個代碼。 Identification of the underlying physiological mechanism for a Reaction Risk. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Alternate Names | Category, Class | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
22. AllergyIntolerance.category | |||||
Definition | 被識別的物質的類別 Category of the identified substance. | ||||
Short | food | medication | environment | biologic | ||||
Comments | 這個資料資料項目被包括在內,因為它目前正在一些臨床系統中被採集。這個資料可以從使用編碼系統的物質中得到,在這種情況下實際上是多餘的。當按類別查詢時,考慮沒有類別的AllergyIntoleranceresource的影響。例如,當查詢類別=藥品時,沒有類別價值的藥品過敏將不會被返回。關於如何用:缺失修飾符查詢類別以獲得沒有類別的過敏,請參考查詢的更多資訊。此外,類別應謹慎使用,因為類別可能是基於寄件者的主觀因素。 This data element has been included because it is currently being captured in some clinical systems. This data can be derived from the substance where coding systems are used, and is effectively redundant in that situation. When searching on category, consider the implications of AllergyIntolerance resources without a category. For example, when searching on category = medication, medication allergies that don't have a category valued will not be returned. Refer to search for more information on how to search category with a :missing modifier to get allergies that don't have a category. Additionally, category should be used with caution because category can be subjective based on the sender. | ||||
Control | 0..* | ||||
Binding | The codes SHALL be taken from AllergyIntoleranceCategoryhttp://hl7.org/fhir/ValueSet/allergy-intolerance-category|4.0.1 (required to http://hl7.org/fhir/ValueSet/allergy-intolerance-category|4.0.1 )確定的物質的類別;應填入所綁定值集中的其中一個代碼。 Category of an identified substance associated with allergies or intolerances. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Alternate Names | Category, Type, Reaction Type, Class | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
24. AllergyIntolerance.criticality | |||||
Definition | 對已識別物質的反應的潛在臨床危害程度,或稱嚴重性估計。 Estimate of the potential clinical harm, or seriousness, of the reaction to the identified substance. | ||||
Short | low | high | unable-to-assess | ||||
Comments | 對於任何對可能引發不良反應的傾向,預設的危險程度應該設定為「低風險」,這表示 至少相對不建議 有意或自願接觸這種物質。如果醫生識別出對更嚴重或可能危及生命的反應,如過敏性休克的傾向,則將其標記為「高風險」,這表示 絕對不建議 有意或自願接觸這種物質。如果缺少這個資料項目,則表示危險程度未知(雖然在其他地方可能已知)。取得疾病層次(condition level)危險性(criticality))的現有系統實際上是在表示危險性的概念,而在反應層次(reaction level)記錄的嚴重性(severity)表示真正的反應嚴重性。現有系統同時記錄疾病危險性和反應嚴重性,可能使用「嚴重性(severity)」一詞來表示兩者。危險性是未來可能出現的最糟糕情況(即不考慮具體情境),而嚴重性則依賴於特定情境。 The default criticality value for any propensity to an adverse reaction should be 'Low Risk', indicating at the very least a relative contraindication to deliberate or voluntary exposure to the substance. 'High Risk' is flagged if the clinician has identified a propensity for a more serious or potentially life-threatening reaction, such as anaphylaxis, and implies an absolute contraindication to deliberate or voluntary exposure to the substance. If this element is missing, the criticality is unknown (though it may be known elsewhere). Systems that capture a severity at the condition level are actually representing the concept of criticality whereas the severity documented at the reaction level is representing the true reaction severity. Existing systems that are capturing both condition criticality and reaction severity may use the term "severity" to represent both. Criticality is the worst it could be in the future (i.e. situation-agnostic) whereas severity is situation-dependent. | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from AllergyIntoleranceCriticalityhttp://hl7.org/fhir/ValueSet/allergy-intolerance-criticality|4.0.1 (required to http://hl7.org/fhir/ValueSet/allergy-intolerance-criticality|4.0.1 )對已識別物質的反應的潛在臨床危害程度,或稱嚴重性估計;應填入所綁定值集中的其中一個代碼。 Estimate of the potential clinical harm, or seriousness, of a reaction to an identified substance. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Alternate Names | Severity, Seriousness, Contra-indication, Risk | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
26. AllergyIntolerance.code | |||||
Definition | 此資料項目是用來代碼化表示有關過敏或不耐症的資訊。它可以表示對某種物質或藥物產品引發不良反應風險的代碼(例如:「乳膠」),也可以表示有關過敏或不耐症的代碼(例如:「乳膠過敏」),或者是表示對特定物質或類別的否定或排除情況的代碼(例如:「無乳膠過敏」),還可以表示一般性的否定性聲明(例如:「無已知過敏」,「無已知藥品過敏」)。需要注意的是:特定反應的物質可能不同於被認為引發風險的物質,但它們之間必須是一致的,在處理這些資訊時,只處理「code」而忽略「reaction.substance」在臨床上必須在是安全的。如果接收系統無法確認AllergyIntolerance.reaction.substance是否符合AllergyIntolerance.code的語義範圍,則應該忽略AllergyIntolerance.reaction.substance。 Code for an allergy or intolerance statement (either a positive or a negated/excluded statement). This may be a code for a substance or pharmaceutical product that is considered to be responsible for the adverse reaction risk (e.g., "Latex"), an allergy or intolerance condition (e.g., "Latex allergy"), or a negated/excluded code for a specific substance or class (e.g., "No latex allergy") or a general or categorical negated statement (e.g., "No known allergy", "No known drug allergies"). Note: the substance for a specific reaction may be different from the substance identified as the cause of the risk, but it must be consistent with it. For instance, it may be a more specific substance (e.g. a brand medication) or a composite product that includes the identified substance. It must be clinically safe to only process the 'code' and ignore the 'reaction.substance'. If a receiving system is unable to confirm that AllergyIntolerance.reaction.substance falls within the semantic scope of AllergyIntolerance.code, then the receiving system should ignore AllergyIntolerance.reaction.substance. | ||||
Short | 表明此過敏或不耐症的代碼Code that identifies the allergy or intolerance | ||||
Comments | 建議在填寫過敏或不耐症相關資料時,儘量使用專業術語。常用的專門術語包括RxNorm、SNOMED CT、DM+D、NDFRT、ICD-9、IDC-10、UNII和ATC等。如果找不到合適的專業術語,則可以用文字表述。文字表述還可以提供更多詳細資訊。 當我們為「code」資料項目指定特定物質或產品代碼時,通常意味著該病人對這種物質或產品有過敏或不耐受反應。在SNOMED CT的過敏模型中,這些物質或產品被視為「過敏物質(Causative agent)」。 另外,還有一個名為「substanceExposureRisk」的擴充資料項目,它比「code」資料項目提供更多靈活性,可以用來描述對特定物質或產品的過敏或不耐受反應,無論是正面還是負面。這個擴充資料項目特別有用於表達「沒有已知過敏」或「沒有不良反應風險」的情況,即使對於那些沒有預先確定「無過敏」概念的物質或產品也適用。如果使用了「substanceExposureRisk」擴充資料項目,則應該省略AllergyIntolerance.code資料項目。 It is strongly recommended that this element be populated using a terminology, where possible. For example, some terminologies used include RxNorm, SNOMED CT, DM+D, NDFRT, ICD-9, IDC-10, UNII, and ATC. Plain text should only be used if there is no appropriate terminology available. Additional details can be specified in the text. When a substance or product code is specified for the 'code' element, the "default" semantic context is that this is a positive statement of an allergy or intolerance (depending on the value of the 'type' element, if present) condition to the specified substance/product. In the corresponding SNOMED CT allergy model, the specified substance/product is the target (destination) of the "Causative agent" relationship. The 'substanceExposureRisk' extension is available as a structured and more flexible alternative to the 'code' element for making positive or negative allergy or intolerance statements. This extension provides the capability to make "no known allergy" (or "no risk of adverse reaction") statements regarding any coded substance/product (including cases when a pre-coordinated "no allergy to x" concept for that substance/product does not exist). If the 'substanceExposureRisk' extension is present, the AllergyIntolerance.code element SHALL be omitted. | ||||
Control | 10..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 AllergyIntoleranceSubstance/Product,ConditionAndNegationCodeshttp://hl7.org/fhir/ValueSet/allergyintolerance-code (extensible to http://hl7.org/fhir/ValueSet/allergyintolerance-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 of the substance/product, allergy or intolerance condition, or negation/exclusion codes for reporting no known allergies. | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Alternate Names | Code | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
28. AllergyIntolerance.patient | |||||
Definition | 患有過敏或不耐症的病人 The patient who has the allergy or intolerance. | ||||
Short | 誰有此過敏或不耐受?Who the sensitivity is for | ||||
Control | 1..1 | ||||
Type | Reference(TW Core Patient, 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())) | ||||
30. AllergyIntolerance.encounter | |||||
Definition | 過敏症或不耐症被確認的就醫事件(Encounter) The encounter when the allergy or intolerance was asserted. | ||||
Short | 過敏或不耐症被確認時的就醫事件(Encounter)Encounter when the allergy or intolerance was asserted | ||||
Control | 0..1 | ||||
Type | Reference(TW Core Encounter, Encounter) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
32. AllergyIntolerance.onset[x] | |||||
Definition | 過敏或不耐症被識別的估計或實際日期、日期時間或年齡。 Estimated or actual date, date-time, or age when allergy or intolerance was identified. | ||||
Short | 過敏或不耐症被識別的時間When allergy or intolerance was identified | ||||
Control | 0..1 | ||||
Type | Choice of: dateTime, Age, Period, Range, string | ||||
[x] Note | SeeChoice of Data Typesfor 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 | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
34. AllergyIntolerance.recordedDate | |||||
Definition | recordedDate指的是這個特定的過敏不耐症紀錄在系統中建立的日期,通常是由系統產生的日期。 The recordedDate represents when this particular AllergyIntolerance record was created in the system, which is often a system-generated date. | ||||
Short | resource實例的第一個版本被記錄的日期Date first version of the resource instance was recorded | ||||
Control | 0..1 | ||||
Type | dateTime | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
36. AllergyIntolerance.recorder | |||||
Definition | 記錄此紀錄並對其內容負責的個人 Individual who recorded the record and takes responsibility for its content. | ||||
Short | 誰記錄了過敏或不耐受Who recorded the sensitivity | ||||
Control | 0..1 | ||||
Type | Reference(TW Core Practitioner, TW Core PractitionerRole, TW Core Patient, TW Core RelatedPerson, Practitioner, PractitionerRole, Patient, RelatedPerson) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Must Support Types | No must-support rules about the choice of types/profiles | ||||
Summary | false | ||||
Alternate Names | Author | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
38. AllergyIntolerance.asserter | |||||
Definition | 有關過敏紀錄的資訊來源 The source of the information about the allergy that is recorded. | ||||
Short | 關於過敏的資訊來源Source of the information about the allergy | ||||
Comments | 記錄者要對內容負有責任,但可以參照他們獲得資訊的來源。 The recorder takes responsibility for the content, but can reference the source from where they got it. | ||||
Control | 0..1 | ||||
Type | Reference(TW Core Patient, TW Core RelatedPerson, TW Core Practitioner, TW Core PractitionerRole, Patient, RelatedPerson, Practitioner, PractitionerRole) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Alternate Names | Source, Informant | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
40. AllergyIntolerance.lastOccurrence | |||||
Definition | 表示最後已知的過敏反應事件發生的日期和/或時間。 Represents the date and/or time of the last known occurrence of a reaction event. | ||||
Short | 最後一次已知反應發生的日期(/時間)Date(/time) of last known occurrence of a reaction | ||||
Comments | 這個日期可能會與某個反應開始日期重複。如果需要以文字表述最後發生的日期,例如:「在童年時」或「10年前」,應該使用 Comment 資料項目。 This date may be replicated by one of the Onset of Reaction dates. Where a textual representation of the date of last occurrence is required e.g. 'In Childhood, '10 years ago' the Comment element should be used. | ||||
Control | 0..1 | ||||
Type | dateTime | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
42. AllergyIntolerance.note | |||||
Definition | 有關不良反應的可能性,這些資訊是未被記錄在其他資料項目中的補充敘述。 Additional narrative about the propensity for the Adverse Reaction, not captured in other fields. | ||||
Short | 其他欄位中沒有記錄的額外文字陳述Additional text not captured in other fields | ||||
Comments | 例如:包括標記為「高風險」的原因,以及與將來接觸或使用該物質相關的指示,比如在重症照護病房內使用或在使用時需要皮質類固醇保護。這些註釋應該與過敏或不耐症作為一般狀況有關,而不是特定事件。對於特定事件的描述和註釋,請使用 AllergyIntolerance.event.description 和 AllergyIntolerance.event.notes。 For example: including reason for flagging a seriousness of 'High Risk'; and instructions related to future exposure or administration of the substance, such as administration within an Intensive Care Unit or under corticosteroid cover. The notes should be related to an allergy or intolerance as a condition in general and not related to any particular episode of it. For episode notes and descriptions, use AllergyIntolerance.event.description and AllergyIntolerance.event.notes. | ||||
Control | 0..* | ||||
Type | Annotation | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
44. AllergyIntolerance.reaction | |||||
Definition | 關於每次接觸特定物質所引起的不良反應事件的細節 Details about each adverse reaction event linked to exposure to the identified substance. | ||||
Short | 暴露於此過敏或不耐症物質的不良反應Adverse Reaction Events linked to exposure to substance | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
46. AllergyIntolerance.reaction.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()) | ||||
48. AllergyIntolerance.reaction.substance | |||||
Definition | 確定與不良反應事件有關的特定物質(或藥品)。注意:對於特定反應而言,所涉及的物質可能與被認為是風險原因的物質不同,但它必須與之一致。例如:它可能是一種更具體的物質(例如:品牌藥物)或包含被確認的物質的複合產品。在臨床上,僅處理「code」而忽略「reaction.substance」必須是安全的。如果接收系統無法確定 AllergyIntolerance.reaction.substance 是否在 AllergyIntolerance.code 的語義範圍內,則接收系統應忽略 AllergyIntolerance.reaction.substance。 Identification of the specific substance (or pharmaceutical product) considered to be responsible for the Adverse Reaction event. Note: the substance for a specific reaction may be different from the substance identified as the cause of the risk, but it must be consistent with it. For instance, it may be a more specific substance (e.g. a brand medication) or a composite product that includes the identified substance. It must be clinically safe to only process the 'code' and ignore the 'reaction.substance'. If a receiving system is unable to confirm that AllergyIntolerance.reaction.substance falls within the semantic scope of AllergyIntolerance.code, then the receiving system should ignore AllergyIntolerance.reaction.substance. | ||||
Short | 被認為是事件原因的特定物質或醫藥產品Specific substance or pharmaceutical product considered to be responsible for event | ||||
Comments | 表現形式可以用一個詞、短語或簡短的描述來表達。例如:噁心、皮疹或無反應。在可能的情況下,最好用專門術語對表現形式進行編碼。這裡輸入的值可作為不良反應清單的一部分顯示在應用螢幕上,正如英國國家醫療服務體系CUI 指南中所建議的那樣,常用的專門術語包括,但不限於SNOMED CT或ICD10。 Coding of the specific substance (or pharmaceutical product) with a terminology capable of triggering decision support should be used wherever possible. The 'code' element allows for the use of a specific substance or pharmaceutical product, or a group or class of substances. In the case of an allergy or intolerance to a class of substances, (for example, "penicillins"), the 'reaction.substance' element could be used to code the specific substance that was identified as having caused the reaction (for example, "amoxycillin"). Duplication of the value in the 'code' and 'reaction.substance' elements is acceptable when a specific substance has been recorded in 'code'. | ||||
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 SubstanceCodehttp://hl7.org/fhir/ValueSet/substance-code (extensible to http://hl7.org/fhir/ValueSet/substance-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 defining the type of the substance (including pharmaceutical products). | ||||
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())) | ||||
50. AllergyIntolerance.reaction.manifestation | |||||
Definition | 觀察到的或與不良反應事件相關的臨床症狀和/或體徵 Clinical symptoms and/or signs that are observed or associated with the adverse reaction event. | ||||
Short | 與此事件相關的臨床症狀/體徵Clinical symptoms/signs associated with the Event | ||||
Comments | 表現形式可以用一個詞、短語或簡短的描述來表達。例如:噁心、皮疹或無反應。在可能的情況下,最好用術語對表現形式進行編碼。這裡輸入的數值可作為不良反應清單的一部分顯示在應用螢幕上,正如英國國家醫療服務體系CUI指南中所建議的那樣。常用的術語包括,但不限於SNOMED CT或ICD10。 Manifestation can be expressed as a single word, phrase or brief description. For example: nausea, rash or no reaction. It is preferable that manifestation should be coded with a terminology, where possible. The values entered here may be used to display on an application screen as part of a list of adverse reactions, as recommended in the UK NHS CUI guidelines. Terminologies commonly used include, but are not limited to, SNOMED CT or ICD10. | ||||
Control | 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 SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findings (extensible to http://hl7.org/fhir/ValueSet/clinical-findings )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。 Clinical symptoms and/or signs that are observed or associated with an Adverse Reaction Event. | ||||
Type | CodeableConcept(TW CodeableConcept) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Alternate Names | Symptoms, Signs | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
52. AllergyIntolerance.reaction.description | |||||
Definition | 關於整個反應的文字描述,如果必要則包括表現形式的細節。 Text description about the reaction as a whole, including details of the manifestation if required. | ||||
Short | 對整個活動的描述Description of the event as a whole | ||||
Comments | 使用描述來提供發生反應的特定事件的任何細節,如情況、反應細節、之前/之後發生了什麼。與事件有關的資訊,但不描述特定的照護應在comment資料項目中記錄。例如:病人在四歲時因鏈球菌感染被注射青黴素,隨後出現嚴重的蕁麻疹。 Use the description to provide any details of a particular event of the occurred reaction such as circumstances, reaction specifics, what happened before/after. Information, related to the event, but not describing a particular care should be captured in the comment field. For example: at the age of four, the patient was given penicillin for strep throat and subsequently developed severe hives. | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Alternate Names | Narrative, Text | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
54. AllergyIntolerance.reaction.onset | |||||
Definition | 記錄反應開始的日期和/或時間 Record of the date and/or time of the onset of the Reaction. | ||||
Short | 症狀顯現的日期(/時間)Date(/time) when manifestations showed | ||||
Control | 0..1 | ||||
Type | dateTime | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
56. AllergyIntolerance.reaction.severity | |||||
Definition | 對整個反應事件的臨床評估,可能會考慮多個不同的表現,以確定反應的嚴重程度。 Clinical assessment of the severity of the reaction event as a whole, potentially considering multiple different manifestations. | ||||
Short | mild | moderate | severemild | moderate | severe (of event as a whole) | ||||
Comments | 這種評估是非常主觀的。可能有一些特定的實務領域已經應用了客觀的評分標準,客觀的評分標準可以作為擴充資料項目包含在這個模型中。 It is acknowledged that this assessment is very subjective. There may be some specific practice domains where objective scales have been applied. Objective scales can be included in this model as extensions. | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from AllergyIntoleranceSeverityhttp://hl7.org/fhir/ValueSet/reaction-event-severity|4.0.1 (required to http://hl7.org/fhir/ValueSet/reaction-event-severity|4.0.1 )整個事件的程度,應填入所綁定值集中的其中一個代碼。 Clinical assessment of the severity of a reaction event as a whole, potentially considering multiple different manifestations. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
58. AllergyIntolerance.reaction.exposureRoute | |||||
Definition | 確認此對象是透過哪種途徑接觸到該物質 Identification of the route by which the subject was exposed to the substance. | ||||
Short | 此對象如何接觸到該物質How the subject was exposed to the substance | ||||
Comments | 應盡可能使用專門術語對接觸途徑進行編碼。 Coding of the route of exposure with a terminology should be used wherever possible. | ||||
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 SNOMEDCTRouteCodeshttp://hl7.org/fhir/ValueSet/route-codes (extensible to http://hl7.org/fhir/ValueSet/route-codes )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 coded concept describing the route or physiological path of administration of a therapeutic agent into or onto the body of a subject. | ||||
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())) | ||||
60. AllergyIntolerance.reaction.note | |||||
Definition | 其他關於不良反應事件的文字表述,這些資訊未在其他資料項目中記錄。 Additional text about the adverse reaction event not captured in other fields. | ||||
Short | 其他資料項目未記錄之關於事件的文字表述Text about event not captured in other fields | ||||
Comments | 使用此資料項目記錄與特定事件間接相關的資訊,但在其他資料項目未記錄的資訊。例如:如果臨床紀錄不再可用,則可根據病人母親提供的資訊來紀錄,儘管病人的母親已經過世。 Use this field to record information indirectly related to a particular event and not captured in the description. For example: Clinical records are no longer available, recorded based on information provided to the patient by her mother and her mother is deceased. | ||||
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())) |
Guidance on how to interpret the contents of this table can be found here
0. AllergyIntolerance | |||||
Definition | 可能對個人產生有害或不希望的生理反應的風險,這種反應是與暴露於某種物質相關的,並且對每個人來說都是獨特的。 | ||||
Short | 過敏或不耐症(通常指:對某種物質有不良反應的風險) | ||||
Comments | 物質包括但不限於:適合個人的劑量正確使用的治療性物質、食品、來自植物或動物的材質、或昆蟲叮咬所釋放的毒液。 | ||||
Control | 0..* | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | Allergy, Intolerance, Adverse Reaction | ||||
Invariants | ait-1: AllergyIntolerance.clinicalStatus SHALL be present if verificationStatus is not entered-in-error. (verificationStatus.coding.where(system = 'http://terminology.hl7.org/CodeSystem/allergyintolerance-verification' and code = 'entered-in-error').exists() or clinicalStatus.exists() )ait-2: AllergyIntolerance.clinicalStatus SHALL NOT be present if verification Status is entered-in-error ( verificationStatus.coding.where(system = 'http://terminology.hl7.org/CodeSystem/allergyintolerance-verification' and code = 'entered-in-error').empty() or clinicalStatus.empty() )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. AllergyIntolerance.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AllergyIntolerance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. AllergyIntolerance.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AllergyIntolerance 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. AllergyIntolerance.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. AllergyIntolerance.language | |||||
Definition | 編寫此resource的語言 | ||||
Short | 用以表述AllergyIntolerance 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. AllergyIntolerance.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 | AllergyIntolerance 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. AllergyIntolerance.contained | |||||
Definition | 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 | Contained, inline Resources | ||||
Comments | 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. AllergyIntolerance.extension | |||||
Definition | 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 | 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() ) | ||||
16. AllergyIntolerance.modifierExtension | |||||
Definition | 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 | Extensions that cannot be ignored | ||||
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 resource that contains them | ||||
Summary | false | ||||
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 | ||||
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. AllergyIntolerance.identifier | |||||
Definition | 由執行者或其他系統指定給這個AllergyIntolerance的業務識別碼,隨著resource更新和從伺服器到伺服器的傳送,這些識別碼保持不變。 | ||||
Short | 過敏或不耐症之外部識別碼 | ||||
Comments | 這是過敏或不耐症紀錄的業務識別碼,不是一個 resource 識別碼(請參見討論小節)。最好的做法是該識別碼只出現在單一個resource實例上,但是實務上有時會要求具有相同識別碼的多個resource實例共存,這些 resources 實例甚至可能屬於不同的resource類型。例如:多個 Patient及一個Person resource實例可能共用同一個社會保險碼(此處是指美國民眾會有唯一可識別的社會保險碼)。 | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 0..* | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | 允許各參與系統按照一致的方式,在不同伺服器之間確認並識別 AllergyIntolerance。 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
20. AllergyIntolerance.clinicalStatus | |||||
Definition | 過敏或不耐症的臨床狀態 | ||||
Short | active | inactive | resolved ,過敏或不耐症的臨床狀態。 | ||||
Comments | 如果 clincalStatus 缺少資料,請查閱討論小節。其資料類型是CodeableConcept,這是因為clinicalStatus涉及到一些臨床判斷,可能需要的具體性超過FHIR值集所要求的範圍。例如:SNOMED代碼可能提供額外的的具體性。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from AllergyIntoleranceClinicalStatusCodes (required to http://hl7.org/fhir/ValueSet/allergyintolerance-clinical|4.0.1 )應填入所綁定值集中的其中一個代碼。 | ||||
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()) ) | ||||
22. AllergyIntolerance.verificationStatus | |||||
Definition | 一個人對某已識別物質(包括醫藥產品)產生反應的可能性或風險有多確定的陳述 | ||||
Short | unconfirmed | confirmed | refuted | entered-in-error ,一個人對特定物質產生反應的可能性或風險有多確定的陳述。 | ||||
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 SHALL be taken from AllergyIntoleranceVerificationStatusCodes (required to http://hl7.org/fhir/ValueSet/allergyintolerance-verification|4.0.1 )應填入所綁定值集中的其中一個代碼。 | ||||
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()) ) | ||||
24. AllergyIntolerance.type | |||||
Definition | 為什麼某人對特定物質(如藥物或食物)會有反應的生理根本原因 | ||||
Short | allergy | intolerance - 根本原因或運作機制(如果知道)。 | ||||
Comments | 過敏反應通常是我們身體免疫系統的一種反應,它被認為可能預示著未來有更嚴重的健康風險。然而,現代醫學研究顯示,有些過去被認為是免疫反應的情況實際上可能並不是,但仍然可能對生命造成危害。有時候,醫生難以確定一個特定反應的機制是免疫相關還是非免疫相關的。此外,「過敏」這個詞經常被廣泛地使用,並且可能與「不耐症」這個詞的使用有所重疊。在實際應用中,這兩個概念的界限可能不太清晰或不容易理解。儘管如此,醫療紀錄中仍然包含了有關過敏反應的資訊,因為許多既有的醫療系統都已經收集了這些資料。免疫學檢測可以提供一些證據幫助確定反應的基礎和引起反應的物質,但這些檢測並不總是百分之百準確,無法100%確定對特定物質的敏感性。如果不清楚反應是否由過敏引起還是由不耐症引起,那麼在醫療紀錄中最好不要具體指定反應的類型,即可忽略及不填寫此資料項目。 | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from AllergyIntoleranceType (required to http://hl7.org/fhir/ValueSet/allergy-intolerance-type|4.0.1 )確定反應風險的基本生理機制;應填入所綁定值集中的其中一個代碼。 | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Alternate Names | Category, Class | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
26. AllergyIntolerance.category | |||||
Definition | 被識別的物質的類別 | ||||
Short | food | medication | environment | biologic | ||||
Comments | 這個資料資料項目被包括在內,因為它目前正在一些臨床系統中被採集。這個資料可以從使用編碼系統的物質中得到,在這種情況下實際上是多餘的。當按類別查詢時,考慮沒有類別的AllergyIntoleranceresource的影響。例如,當查詢類別=藥品時,沒有類別價值的藥品過敏將不會被返回。關於如何用:缺失修飾符查詢類別以獲得沒有類別的過敏,請參考查詢的更多資訊。此外,類別應謹慎使用,因為類別可能是基於寄件者的主觀因素。 | ||||
Control | 0..* | ||||
Binding | The codes SHALL be taken from AllergyIntoleranceCategory (required to http://hl7.org/fhir/ValueSet/allergy-intolerance-category|4.0.1 )確定的物質的類別;應填入所綁定值集中的其中一個代碼。 | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Alternate Names | Category, Type, Reaction Type, Class | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
28. AllergyIntolerance.criticality | |||||
Definition | 對已識別物質的反應的潛在臨床危害程度,或稱嚴重性估計。 | ||||
Short | low | high | unable-to-assess | ||||
Comments | 對於任何對可能引發不良反應的傾向,預設的危險程度應該設定為「低風險」,這表示 至少相對不建議 有意或自願接觸這種物質。如果醫生識別出對更嚴重或可能危及生命的反應,如過敏性休克的傾向,則將其標記為「高風險」,這表示 絕對不建議 有意或自願接觸這種物質。如果缺少這個資料項目,則表示危險程度未知(雖然在其他地方可能已知)。取得疾病層次(condition level)危險性(criticality))的現有系統實際上是在表示危險性的概念,而在反應層次(reaction level)記錄的嚴重性(severity)表示真正的反應嚴重性。現有系統同時記錄疾病危險性和反應嚴重性,可能使用「嚴重性(severity)」一詞來表示兩者。危險性是未來可能出現的最糟糕情況(即不考慮具體情境),而嚴重性則依賴於特定情境。 | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from AllergyIntoleranceCriticality (required to http://hl7.org/fhir/ValueSet/allergy-intolerance-criticality|4.0.1 )對已識別物質的反應的潛在臨床危害程度,或稱嚴重性估計;應填入所綁定值集中的其中一個代碼。 | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Alternate Names | Severity, Seriousness, Contra-indication, Risk | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
30. AllergyIntolerance.code | |||||
Definition | 此資料項目是用來代碼化表示有關過敏或不耐症的資訊。它可以表示對某種物質或藥物產品引發不良反應風險的代碼(例如:「乳膠」),也可以表示有關過敏或不耐症的代碼(例如:「乳膠過敏」),或者是表示對特定物質或類別的否定或排除情況的代碼(例如:「無乳膠過敏」),還可以表示一般性的否定性聲明(例如:「無已知過敏」,「無已知藥品過敏」)。需要注意的是:特定反應的物質可能不同於被認為引發風險的物質,但它們之間必須是一致的,在處理這些資訊時,只處理「code」而忽略「reaction.substance」在臨床上必須在是安全的。如果接收系統無法確認AllergyIntolerance.reaction.substance是否符合AllergyIntolerance.code的語義範圍,則應該忽略AllergyIntolerance.reaction.substance。 | ||||
Short | 表明此過敏或不耐症的代碼 | ||||
Comments | 建議在填寫過敏或不耐症相關資料時,儘量使用專業術語。常用的專門術語包括RxNorm、SNOMED CT、DM+D、NDFRT、ICD-9、IDC-10、UNII和ATC等。如果找不到合適的專業術語,則可以用文字表述。文字表述還可以提供更多詳細資訊。 當我們為「code」資料項目指定特定物質或產品代碼時,通常意味著該病人對這種物質或產品有過敏或不耐受反應。在SNOMED CT的過敏模型中,這些物質或產品被視為「過敏物質(Causative agent)」。 另外,還有一個名為「substanceExposureRisk」的擴充資料項目,它比「code」資料項目提供更多靈活性,可以用來描述對特定物質或產品的過敏或不耐受反應,無論是正面還是負面。這個擴充資料項目特別有用於表達「沒有已知過敏」或「沒有不良反應風險」的情況,即使對於那些沒有預先確定「無過敏」概念的物質或產品也適用。如果使用了「substanceExposureRisk」擴充資料項目,則應該省略AllergyIntolerance.code資料項目。 | ||||
Control | 1..1 This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from AllergyIntoleranceSubstance/Product,ConditionAndNegationCodes (extensible to http://hl7.org/fhir/ValueSet/allergyintolerance-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 | ||||
Must Support | true | ||||
Alternate Names | Code | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
32. AllergyIntolerance.patient | |||||
Definition | 患有過敏或不耐症的病人 | ||||
Short | 誰有此過敏或不耐受? | ||||
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()) ) | ||||
34. AllergyIntolerance.encounter | |||||
Definition | 過敏症或不耐症被確認的就醫事件(Encounter) | ||||
Short | 過敏或不耐症被確認時的就醫事件(Encounter) | ||||
Control | 0..1 | ||||
Type | Reference(TW Core Encounter) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
36. AllergyIntolerance.onset[x] | |||||
Definition | 過敏或不耐症被識別的估計或實際日期、日期時間或年齡。 | ||||
Short | 過敏或不耐症被識別的時間 | ||||
Control | 0..1 | ||||
Type | Choice of: dateTime, Age, Period, Range, string | ||||
[x] Note | SeeChoice of Data Typesfor 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 | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
38. AllergyIntolerance.recordedDate | |||||
Definition | recordedDate指的是這個特定的過敏不耐症紀錄在系統中建立的日期,通常是由系統產生的日期。 | ||||
Short | resource實例的第一個版本被記錄的日期 | ||||
Control | 0..1 | ||||
Type | dateTime | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
40. AllergyIntolerance.recorder | |||||
Definition | 記錄此紀錄並對其內容負責的個人 | ||||
Short | 誰記錄了過敏或不耐受 | ||||
Control | 0..1 | ||||
Type | Reference(TW Core Practitioner, TW Core PractitionerRole, TW Core Patient, TW Core RelatedPerson) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Must Support Types | No must-support rules about the choice of types/profiles | ||||
Summary | false | ||||
Alternate Names | Author | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
42. AllergyIntolerance.asserter | |||||
Definition | 有關過敏紀錄的資訊來源 | ||||
Short | 關於過敏的資訊來源 | ||||
Comments | 記錄者要對內容負有責任,但可以參照他們獲得資訊的來源。 | ||||
Control | 0..1 | ||||
Type | Reference(TW Core Patient, TW Core RelatedPerson, TW Core Practitioner, TW Core PractitionerRole) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Alternate Names | Source, Informant | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
44. AllergyIntolerance.lastOccurrence | |||||
Definition | 表示最後已知的過敏反應事件發生的日期和/或時間。 | ||||
Short | 最後一次已知反應發生的日期(/時間) | ||||
Comments | 這個日期可能會與某個反應開始日期重複。如果需要以文字表述最後發生的日期,例如:「在童年時」或「10年前」,應該使用 Comment 資料項目。 | ||||
Control | 0..1 | ||||
Type | dateTime | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
46. AllergyIntolerance.note | |||||
Definition | 有關不良反應的可能性,這些資訊是未被記錄在其他資料項目中的補充敘述。 | ||||
Short | 其他欄位中沒有記錄的額外文字陳述 | ||||
Comments | 例如:包括標記為「高風險」的原因,以及與將來接觸或使用該物質相關的指示,比如在重症照護病房內使用或在使用時需要皮質類固醇保護。這些註釋應該與過敏或不耐症作為一般狀況有關,而不是特定事件。對於特定事件的描述和註釋,請使用 AllergyIntolerance.event.description 和 AllergyIntolerance.event.notes。 | ||||
Control | 0..* | ||||
Type | Annotation | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
48. AllergyIntolerance.reaction | |||||
Definition | 關於每次接觸特定物質所引起的不良反應事件的細節 | ||||
Short | 暴露於此過敏或不耐症物質的不良反應 | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
50. AllergyIntolerance.reaction.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 | ||||
52. AllergyIntolerance.reaction.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() ) | ||||
54. AllergyIntolerance.reaction.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() ) | ||||
56. AllergyIntolerance.reaction.substance | |||||
Definition | 確定與不良反應事件有關的特定物質(或藥品)。注意:對於特定反應而言,所涉及的物質可能與被認為是風險原因的物質不同,但它必須與之一致。例如:它可能是一種更具體的物質(例如:品牌藥物)或包含被確認的物質的複合產品。在臨床上,僅處理「code」而忽略「reaction.substance」必須是安全的。如果接收系統無法確定 AllergyIntolerance.reaction.substance 是否在 AllergyIntolerance.code 的語義範圍內,則接收系統應忽略 AllergyIntolerance.reaction.substance。 | ||||
Short | 被認為是事件原因的特定物質或醫藥產品 | ||||
Comments | 表現形式可以用一個詞、短語或簡短的描述來表達。例如:噁心、皮疹或無反應。在可能的情況下,最好用專門術語對表現形式進行編碼。這裡輸入的值可作為不良反應清單的一部分顯示在應用螢幕上,正如英國國家醫療服務體系CUI 指南中所建議的那樣,常用的專門術語包括,但不限於SNOMED CT或ICD10。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from SubstanceCode (extensible to http://hl7.org/fhir/ValueSet/substance-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()) ) | ||||
58. AllergyIntolerance.reaction.manifestation | |||||
Definition | 觀察到的或與不良反應事件相關的臨床症狀和/或體徵 | ||||
Short | 與此事件相關的臨床症狀/體徵 | ||||
Comments | 表現形式可以用一個詞、短語或簡短的描述來表達。例如:噁心、皮疹或無反應。在可能的情況下,最好用術語對表現形式進行編碼。這裡輸入的數值可作為不良反應清單的一部分顯示在應用螢幕上,正如英國國家醫療服務體系CUI指南中所建議的那樣。常用的術語包括,但不限於SNOMED CT或ICD10。 | ||||
Control | 1..* This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from SNOMEDCTClinicalFindings (extensible to http://hl7.org/fhir/ValueSet/clinical-findings )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 | ||||
Alternate Names | Symptoms, Signs | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
60. AllergyIntolerance.reaction.description | |||||
Definition | 關於整個反應的文字描述,如果必要則包括表現形式的細節。 | ||||
Short | 對整個活動的描述 | ||||
Comments | 使用描述來提供發生反應的特定事件的任何細節,如情況、反應細節、之前/之後發生了什麼。與事件有關的資訊,但不描述特定的照護應在comment資料項目中記錄。例如:病人在四歲時因鏈球菌感染被注射青黴素,隨後出現嚴重的蕁麻疹。 | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Alternate Names | Narrative, Text | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
62. AllergyIntolerance.reaction.onset | |||||
Definition | 記錄反應開始的日期和/或時間 | ||||
Short | 症狀顯現的日期(/時間) | ||||
Control | 0..1 | ||||
Type | dateTime | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
64. AllergyIntolerance.reaction.severity | |||||
Definition | 對整個反應事件的臨床評估,可能會考慮多個不同的表現,以確定反應的嚴重程度。 | ||||
Short | mild | moderate | severe | ||||
Comments | 這種評估是非常主觀的。可能有一些特定的實務領域已經應用了客觀的評分標準,客觀的評分標準可以作為擴充資料項目包含在這個模型中。 | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from AllergyIntoleranceSeverity (required to http://hl7.org/fhir/ValueSet/reaction-event-severity|4.0.1 )整個事件的程度,應填入所綁定值集中的其中一個代碼。 | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
66. AllergyIntolerance.reaction.exposureRoute | |||||
Definition | 確認此對象是透過哪種途徑接觸到該物質 | ||||
Short | 此對象如何接觸到該物質 | ||||
Comments | 應盡可能使用專門術語對接觸途徑進行編碼。 | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from SNOMEDCTRouteCodes (extensible to http://hl7.org/fhir/ValueSet/route-codes )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()) ) | ||||
68. AllergyIntolerance.reaction.note | |||||
Definition | 其他關於不良反應事件的文字表述,這些資訊未在其他資料項目中記錄。 | ||||
Short | 其他資料項目未記錄之關於事件的文字表述 | ||||
Comments | 使用此資料項目記錄與特定事件間接相關的資訊,但在其他資料項目未記錄的資訊。例如:如果臨床紀錄不再可用,則可根據病人母親提供的資訊來紀錄,儘管病人的母親已經過世。 | ||||
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()) ) |