臺灣長期照顧實作指引(TW LTC IG)
1.1.0 - STU 1.1.0

臺灣長期照顧實作指引(TW LTC IG) - Local Development build (v1.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: 在宅急症－臨床評估

Official URL: http://ltc-ig.fhir.tw/StructureDefinition/HAHClinicalImpression Version: 1.1.0
Draft as of 2026-09-29 Computable Name: HAHClinicalImpression

記錄評估人員對病情的判斷、發現與摘要。

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!Σ 1..1 code in-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
... encounter SΣ 1..1 Reference(在宅急症－就診基礎) Encounter created as part of
... effective[x] SΣ 1..1 Time of assessment
.... effectiveDateTime dateTime
.... effectivePeriod Period
... date SΣ 1..1 dateTime When the assessment was documented
... assessor SΣ 1..1 Reference(長期照顧－照顧服務提供者 | 長期照顧－服務人員角色) The clinician performing the assessment
... problem Σ 0..* Reference(在宅急症－診斷與照護問題) Relevant impressions of patient state
... summary S 1..1 string Summary of the assessment
... finding S 0..* BackboneElement Possible or likely findings and diagnoses
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
... supportingInfo S 0..* Reference(Resource) Information supporting the clinical impression
... note 0..* Annotation 評估補充說明

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalImpression.status Base required Clinical Impression Status 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClinicalImpression If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClinicalImpression If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClinicalImpression A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from ClinicalImpression

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... subject 1..1 Reference(在宅急症－個案) Patient or group assessed
... encounter S 1..1 Reference(在宅急症－就診基礎) Encounter created as part of
... effective[x] S 1..1 dateTime, Period Time of assessment
... assessor S 1..1 Reference(長期照顧－照顧服務提供者 | 長期照顧－服務人員角色) The clinician performing the assessment
... problem 0..* Reference(在宅急症－診斷與照護問題) Relevant impressions of patient state
... summary S 1..1 string Summary of the assessment
... finding S 0..* BackboneElement Possible or likely findings and diagnoses
... supportingInfo S 0..* Reference(Resource) Information supporting the clinical impression
... note 0..* Annotation 評估補充說明

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business identifier
... status ?!Σ 1..1 code in-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
... statusReason 0..1 CodeableConcept Reason for current status
Binding Description: (example): Codes identifying the reason for the current state of a clinical impression.
... code Σ 0..1 CodeableConcept Kind of assessment performed
Binding Description: (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed.
... description Σ 0..1 string Why/how the assessment was performed
... subject Σ 1..1 Reference(在宅急症－個案) Patient or group assessed
... encounter SΣ 1..1 Reference(在宅急症－就診基礎) Encounter created as part of
... effective[x] SΣ 1..1 Time of assessment
.... effectiveDateTime dateTime
.... effectivePeriod Period
... date SΣ 1..1 dateTime When the assessment was documented
... assessor SΣ 1..1 Reference(長期照顧－照顧服務提供者 | 長期照顧－服務人員角色) The clinician performing the assessment
... previous 0..1 Reference(ClinicalImpression) Reference to last assessment
... problem Σ 0..* Reference(在宅急症－診斷與照護問題) Relevant impressions of patient state
... investigation 0..* BackboneElement One or more sets of investigations (signs, symptoms, etc.)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 CodeableConcept A name/code for the set
Binding: InvestigationType (example): A name/code for a set of investigations.
.... item 0..* Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media) Record of a specific investigation
... protocol 0..* uri Clinical Protocol followed
... summary S 1..1 string Summary of the assessment
... finding S 0..* BackboneElement Possible or likely findings and diagnoses
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemCodeableConcept 0..1 CodeableConcept What was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.
.... itemReference 0..1 Reference(Condition | Observation | Media) What was found
.... basis 0..1 string Which investigations support finding
... prognosisCodeableConcept 0..* CodeableConcept Estimate of likely outcome
Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings.
... prognosisReference 0..* Reference(RiskAssessment) RiskAssessment expressing likely outcome
... supportingInfo S 0..* Reference(Resource) Information supporting the clinical impression
... note 0..* Annotation 評估補充說明

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalImpression.language Base preferred Common Languages 📍4.0.1 FHIR Std.
ClinicalImpression.status Base required Clinical Impression Status 📍4.0.1 FHIR Std.
ClinicalImpression.statusReason Base example Not State Unknown
ClinicalImpression.code Base example Not State Unknown
ClinicalImpression.investigation.​code Base example Investigation Type 📍4.0.1 FHIR Std.
ClinicalImpression.finding.​itemCodeableConcept Base example Condition/Problem/Diagnosis Codes 📍4.0.1 FHIR Std.
ClinicalImpression.prognosisCodeableConcept Base example Clinical Impression Prognosis 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClinicalImpression If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClinicalImpression If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClinicalImpression A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!Σ 1..1 code in-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
... encounter SΣ 1..1 Reference(在宅急症－就診基礎) Encounter created as part of
... effective[x] SΣ 1..1 Time of assessment
.... effectiveDateTime dateTime
.... effectivePeriod Period
... date SΣ 1..1 dateTime When the assessment was documented
... assessor SΣ 1..1 Reference(長期照顧－照顧服務提供者 | 長期照顧－服務人員角色) The clinician performing the assessment
... problem Σ 0..* Reference(在宅急症－診斷與照護問題) Relevant impressions of patient state
... summary S 1..1 string Summary of the assessment
... finding S 0..* BackboneElement Possible or likely findings and diagnoses
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
... supportingInfo S 0..* Reference(Resource) Information supporting the clinical impression
... note 0..* Annotation 評估補充說明

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalImpression.status Base required Clinical Impression Status 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClinicalImpression If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClinicalImpression If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClinicalImpression A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Differential View

This structure is derived from ClinicalImpression

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... subject 1..1 Reference(在宅急症－個案) Patient or group assessed
... encounter S 1..1 Reference(在宅急症－就診基礎) Encounter created as part of
... effective[x] S 1..1 dateTime, Period Time of assessment
... assessor S 1..1 Reference(長期照顧－照顧服務提供者 | 長期照顧－服務人員角色) The clinician performing the assessment
... problem 0..* Reference(在宅急症－診斷與照護問題) Relevant impressions of patient state
... summary S 1..1 string Summary of the assessment
... finding S 0..* BackboneElement Possible or likely findings and diagnoses
... supportingInfo S 0..* Reference(Resource) Information supporting the clinical impression
... note 0..* Annotation 評估補充說明

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business identifier
... status ?!Σ 1..1 code in-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
... statusReason 0..1 CodeableConcept Reason for current status
Binding Description: (example): Codes identifying the reason for the current state of a clinical impression.
... code Σ 0..1 CodeableConcept Kind of assessment performed
Binding Description: (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed.
... description Σ 0..1 string Why/how the assessment was performed
... subject Σ 1..1 Reference(在宅急症－個案) Patient or group assessed
... encounter SΣ 1..1 Reference(在宅急症－就診基礎) Encounter created as part of
... effective[x] SΣ 1..1 Time of assessment
.... effectiveDateTime dateTime
.... effectivePeriod Period
... date SΣ 1..1 dateTime When the assessment was documented
... assessor SΣ 1..1 Reference(長期照顧－照顧服務提供者 | 長期照顧－服務人員角色) The clinician performing the assessment
... previous 0..1 Reference(ClinicalImpression) Reference to last assessment
... problem Σ 0..* Reference(在宅急症－診斷與照護問題) Relevant impressions of patient state
... investigation 0..* BackboneElement One or more sets of investigations (signs, symptoms, etc.)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 CodeableConcept A name/code for the set
Binding: InvestigationType (example): A name/code for a set of investigations.
.... item 0..* Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media) Record of a specific investigation
... protocol 0..* uri Clinical Protocol followed
... summary S 1..1 string Summary of the assessment
... finding S 0..* BackboneElement Possible or likely findings and diagnoses
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemCodeableConcept 0..1 CodeableConcept What was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.
.... itemReference 0..1 Reference(Condition | Observation | Media) What was found
.... basis 0..1 string Which investigations support finding
... prognosisCodeableConcept 0..* CodeableConcept Estimate of likely outcome
Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings.
... prognosisReference 0..* Reference(RiskAssessment) RiskAssessment expressing likely outcome
... supportingInfo S 0..* Reference(Resource) Information supporting the clinical impression
... note 0..* Annotation 評估補充說明

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalImpression.language Base preferred Common Languages 📍4.0.1 FHIR Std.
ClinicalImpression.status Base required Clinical Impression Status 📍4.0.1 FHIR Std.
ClinicalImpression.statusReason Base example Not State Unknown
ClinicalImpression.code Base example Not State Unknown
ClinicalImpression.investigation.​code Base example Investigation Type 📍4.0.1 FHIR Std.
ClinicalImpression.finding.​itemCodeableConcept Base example Condition/Problem/Diagnosis Codes 📍4.0.1 FHIR Std.
ClinicalImpression.prognosisCodeableConcept Base example Clinical Impression Prognosis 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClinicalImpression If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClinicalImpression If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClinicalImpression A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron