臺灣長期照顧實作指引 (Taiwan Long-Term Care FHIR Implementation Guide) - Local Development build (v0.1.1) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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Resource Profile: TWLTC Condition Crush

長照機構住民的壓傷資料

Usage:

• Refer to this Resource Profile: TWLTC Composition Referral

Formal Views of Profile Content

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

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from TWCoreCondition

Name	Flags	Card.	Type	Description & Constraints
Condition			TWCoreCondition
code		1..1	CodeableConceptTW	壓傷狀況 Binding: 壓傷狀況值集 (required)
coding		1..1	CodingTW	壓傷狀況代碼
system		1..1	uri	專門術語系統（terminology system）的識別 Required Pattern: http://ltc-ig.fhir.tw/ValueSet/ReferralConditionCrushVS-TWLTC
code		1..1	code	個案是否有壓傷？如果代碼為 crush，則需填寫備註以描述壓傷狀況
note		0..1	Annotation	壓傷狀況與類別備註，應填寫部位、等級與大小(cm^2)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Condition.code	required	ReferralConditionCrushVSTWLTC (a valid code from 轉介單壓傷狀況代碼) http://ltc-ig.fhir.tw/ValueSet/ReferralConditionCrushVS-TWLTC from this IG

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	TWCoreCondition	有關病情、問題或診斷的詳細資訊 con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
implicitRules	?!Σ	0..1	uri	創建此內容所依據的一組規則
modifierExtension	?!	0..*	Extension	此擴充的資料項目可能會完全修正或改變其他資料項目的意涵，需特別留意。
clinicalStatus	S	1..1	CodeableConceptTW	active | recurrence | relapse | inactive | remission | resolved ，病情、問題或診斷的臨床狀態。 Binding: ConditionClinicalStatusCodes (required): 應填入所綁定值集中的其中一個代碼。
verificationStatus	S	0..1	CodeableConceptTW	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error ，支持或拒絕病情、問題或診斷的臨床狀態的驗證狀態。 Binding: ConditionVerificationStatus (required): 應填入所綁定值集中的其中一個代碼。
category	S	1..1	CodeableConceptTW	problem-list-item | encounter-diagnosis ，指定病情、問題或診斷的類別。 Binding: ConditionCategoryCodes (extensible): 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。
severity	S	0..1	CodeableConceptTW	病情、問題或診斷的主觀嚴重程度 Binding: Condition/DiagnosisSeverity (extensible): 臨床醫生對病情、問題或診斷嚴重程度的主觀評價；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。
code	S	1..1	CodeableConceptTW	壓傷狀況 Binding: 壓傷狀況值集 (required)
Slices for coding	S	1..1	CodingTW	壓傷狀況代碼 Slice: Unordered, Open by pattern:$this
coding:All Slices				Content/Rules for all slices
system	SΣ	1..1	uri	專門術語系統（terminology system）的識別 Required Pattern: http://ltc-ig.fhir.tw/ValueSet/ReferralConditionCrushVS-TWLTC
code	SΣ	1..1	code	個案是否有壓傷？如果代碼為 crush，則需填寫備註以描述壓傷狀況
display	SΣ	0..1	string	由系統定義的表示法
coding:icd10-cm-2021	S	0..1	CodingTW	此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼，涵蓋範圍相對完整，可免費使用，可優先選用此代碼。 Binding: 臺灣健保署2021年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別；應填入所綁定值集中的其中一個代碼。
coding:icd10-cm-2014	S	0..1	CodingTW	此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼，涵蓋範圍相對完整，可免費使用，可優先選用此代碼。 Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別；應填入所綁定值集中的其中一個代碼。
coding:icd9-cm-2001	S	0..1	CodingTW	由專門術語系統（terminology system）定義的代碼 Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required)
coding:absentOrUnknownProblem	S	0..1	CodingTW	不存在的問題或未知問題的代碼 Binding: Absent or Unknown Problems - IPS (required): 應填入所綁定值集中的其中一個代碼。
coding:sct	S	0..1	CodingTW	此為SNOMED CT診斷代碼，若機構已有購買相關授權，亦可使用。 Binding: SNOMED CT診斷代碼值集 (required): 應填入所綁定值集中的其中一個代碼。
text	SΣ	0..1	string	概念的文字表示法
bodySite	S	0..*	CodeableConceptTW	如果相關請填寫解剖位置 Binding: SNOMEDCTBodyStructures (extensible): 描述解剖位置的代碼。可包括側面；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。
subject	SΣ	1..1	Reference(TW Core Patient | Group)	誰有此病情、問題或診斷？
onset[x]	SΣ	0..1		估計的或實際的日期、日期—時間或年齡。
onsetDateTime			dateTime
abatement[x]	SC	0..1		何時解決/緩解
abatementDateTime			dateTime
asserter	SΣ	0..1	Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | RelatedPerson)	聲稱有此病情、問題或診斷的人
note	S	0..1	Annotation	壓傷狀況與類別備註，應填寫部位、等級與大小(cm^2)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard
Condition.category	extensible	ConditionCategoryCodes http://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard
Condition.severity	extensible	Condition/DiagnosisSeverity http://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard
Condition.code	required	ReferralConditionCrushVSTWLTC (a valid code from 轉介單壓傷狀況代碼) http://ltc-ig.fhir.tw/ValueSet/ReferralConditionCrushVS-TWLTC from this IG
Condition.code.coding:icd10-cm-2021	required	TW2021ICD10CM https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2021-tw
Condition.code.coding:icd10-cm-2014	required	TW2014ICD10CM https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2014-tw
Condition.code.coding:icd9-cm-2001	required	TW2001ICD9CM https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw
Condition.code.coding:absentOrUnknownProblem	required	AbsentOrUnknownProblemsUvIps http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips
Condition.code.coding:sct	required	TWConditionCodeSCT https://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw
Condition.bodySite	extensible	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
con-3	best practice	Condition	Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4	error	Condition	If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5	error	Condition	Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2	error	Condition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Condition	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	Condition	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	Condition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Condition	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()

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	TWCoreCondition	有關病情、問題或診斷的詳細資訊 con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
id	Σ	0..1	id	不重複的ID用以識別儲存在特定FHIR Server中的Condition紀錄，通常又稱為邏輯性ID。
meta	Σ	0..1	Meta	此Condition Resource的metadata
implicitRules	?!Σ	0..1	uri	創建此內容所依據的一組規則
language		0..1	code	用以表述Condition Resource內容的語言。 Binding: CommonLanguages (preferred): 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。 Additional Bindings Purpose AllLanguages Max Binding Example Value: zh-TW
text		0..1	Narrative	Condition Resource之內容摘要以供人閱讀
contained		0..*	Resource	內嵌的（contained）、行內的Resources
extension		0..*	Extension	擴充的資料項目
modifierExtension	?!	0..*	Extension	此擴充的資料項目可能會完全修正或改變其他資料項目的意涵，需特別留意。
identifier	Σ	0..*	Identifier	此病情、問題或診斷的外部識別碼
clinicalStatus	S	1..1	CodeableConceptTW	active | recurrence | relapse | inactive | remission | resolved ，病情、問題或診斷的臨床狀態。 Binding: ConditionClinicalStatusCodes (required): 應填入所綁定值集中的其中一個代碼。
verificationStatus	S	0..1	CodeableConceptTW	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error ，支持或拒絕病情、問題或診斷的臨床狀態的驗證狀態。 Binding: ConditionVerificationStatus (required): 應填入所綁定值集中的其中一個代碼。
category	S	1..1	CodeableConceptTW	problem-list-item | encounter-diagnosis ，指定病情、問題或診斷的類別。 Binding: ConditionCategoryCodes (extensible): 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。
severity	S	0..1	CodeableConceptTW	病情、問題或診斷的主觀嚴重程度 Binding: Condition/DiagnosisSeverity (extensible): 臨床醫生對病情、問題或診斷嚴重程度的主觀評價；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。
code	S	1..1	CodeableConceptTW	壓傷狀況 Binding: 壓傷狀況值集 (required)
id		0..1	string	唯一可識別ID，以供資料項目間相互參照。
extension		0..*	Extension	擴充的資料項目 Slice: Unordered, Open by value:url
Slices for coding	S	1..1	CodingTW	壓傷狀況代碼 Slice: Unordered, Open by pattern:$this
coding:All Slices				Content/Rules for all slices
id		0..1	string	唯一可識別ID，以供資料項目間相互參照。
extension		0..*	Extension	擴充的資料項目 Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	專門術語系統（terminology system）的識別 Required Pattern: http://ltc-ig.fhir.tw/ValueSet/ReferralConditionCrushVS-TWLTC
version	Σ	0..1	string	系統的版本—如果相關的話
code	SΣ	1..1	code	個案是否有壓傷？如果代碼為 crush，則需填寫備註以描述壓傷狀況
display	SΣ	0..1	string	由系統定義的表示法
userSelected	Σ	0..1	boolean	此編碼是否由使用者直接選擇？
coding:icd10-cm-2021	S	0..1	CodingTW	此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼，涵蓋範圍相對完整，可免費使用，可優先選用此代碼。 Binding: 臺灣健保署2021年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別；應填入所綁定值集中的其中一個代碼。
coding:icd10-cm-2014	S	0..1	CodingTW	此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼，涵蓋範圍相對完整，可免費使用，可優先選用此代碼。 Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別；應填入所綁定值集中的其中一個代碼。
coding:icd9-cm-2001	S	0..1	CodingTW	由專門術語系統（terminology system）定義的代碼 Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required)
coding:absentOrUnknownProblem	S	0..1	CodingTW	不存在的問題或未知問題的代碼 Binding: Absent or Unknown Problems - IPS (required): 應填入所綁定值集中的其中一個代碼。
coding:sct	S	0..1	CodingTW	此為SNOMED CT診斷代碼，若機構已有購買相關授權，亦可使用。 Binding: SNOMED CT診斷代碼值集 (required): 應填入所綁定值集中的其中一個代碼。
text	SΣ	0..1	string	概念的文字表示法
bodySite	S	0..*	CodeableConceptTW	如果相關請填寫解剖位置 Binding: SNOMEDCTBodyStructures (extensible): 描述解剖位置的代碼。可包括側面；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。
subject	SΣ	1..1	Reference(TW Core Patient | Group)	誰有此病情、問題或診斷？
encounter	Σ	0..1	Reference(TW Core Encounter)	作為病情、問題或診斷紀錄的一部分的就醫（Encounter）紀錄
onset[x]	SΣ	0..1		估計的或實際的日期、日期—時間或年齡。
onsetDateTime			dateTime S
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
abatement[x]	SC	0..1		何時解決/緩解
abatementDateTime			dateTime S
abatementAge			Age
abatementPeriod			Period
abatementRange			Range
abatementString			string
recordedDate	Σ	0..1	dateTime	記錄的日期
recorder	Σ	0..1	Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | RelatedPerson)	誰記錄此病情、問題或診斷
asserter	SΣ	0..1	Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | RelatedPerson)	聲稱有此病情、問題或診斷的人
stage	C	0..*	BackboneElement	分期（stage）／分級（grade），通常是正式的評估。 con-1: Stage SHALL have summary or assessment
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
summary		0..1	CodeableConceptTW	簡單的摘要（特定疾病）。 Binding: ConditionStage (extensible): 描述病情、問題或診斷分期的代碼（例如：癌症分期）。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。
assessment	C	0..*	Reference(ClinicalImpression | TW Core DiagnosticReport | TW Core Observation Laboratory Result | TW Core Observation Vital Signs)	正式的評估記錄
type		0..1	CodeableConceptTW	分期的種類 Binding: ConditionStageType (extensible): 病情、問題或診斷分期種類的代碼（如臨床或病理）；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。
evidence	C	0..*	BackboneElement	支持的證據 con-2: evidence SHALL have code or details
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		0..*	CodeableConceptTW	表現／症狀 Binding: ManifestationAndSymptomCodes (extensible): 病情、問題或診斷的表現或症狀之代碼；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。
detail	ΣC	0..*	Reference(Resource)	在其他地方找到的支持資訊
note	S	0..1	Annotation	壓傷狀況與類別備註，應填寫部位、等級與大小(cm^2)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Condition.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard
Condition.category	extensible	ConditionCategoryCodes http://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard
Condition.severity	extensible	Condition/DiagnosisSeverity http://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard
Condition.code	required	ReferralConditionCrushVSTWLTC (a valid code from 轉介單壓傷狀況代碼) http://ltc-ig.fhir.tw/ValueSet/ReferralConditionCrushVS-TWLTC from this IG
Condition.code.coding:icd10-cm-2021	required	TW2021ICD10CM https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2021-tw
Condition.code.coding:icd10-cm-2014	required	TW2014ICD10CM https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2014-tw
Condition.code.coding:icd9-cm-2001	required	TW2001ICD9CM https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw
Condition.code.coding:absentOrUnknownProblem	required	AbsentOrUnknownProblemsUvIps http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips
Condition.code.coding:sct	required	TWConditionCodeSCT https://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw
Condition.bodySite	extensible	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Condition.stage.summary	extensible	ConditionStage http://hl7.org/fhir/ValueSet/condition-stage from the FHIR Standard
Condition.stage.type	extensible	ConditionStageType http://hl7.org/fhir/ValueSet/condition-stage-type from the FHIR Standard
Condition.evidence.code	extensible	ManifestationAndSymptomCodes http://hl7.org/fhir/ValueSet/manifestation-or-symptom from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
con-1	error	Condition.stage	Stage SHALL have summary or assessment : summary.exists() or assessment.exists()
con-2	error	Condition.evidence	evidence SHALL have code or details : code.exists() or detail.exists()
con-3	best practice	Condition	Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4	error	Condition	If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5	error	Condition	Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2	error	Condition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Condition	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	Condition	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	Condition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Condition	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 TWCoreCondition

Summary

Mandatory: 4 elements

Differential View

This structure is derived from TWCoreCondition

Name	Flags	Card.	Type	Description & Constraints
Condition			TWCoreCondition
code		1..1	CodeableConceptTW	壓傷狀況 Binding: 壓傷狀況值集 (required)
coding		1..1	CodingTW	壓傷狀況代碼
system		1..1	uri	專門術語系統（terminology system）的識別 Required Pattern: http://ltc-ig.fhir.tw/ValueSet/ReferralConditionCrushVS-TWLTC
code		1..1	code	個案是否有壓傷？如果代碼為 crush，則需填寫備註以描述壓傷狀況
note		0..1	Annotation	壓傷狀況與類別備註，應填寫部位、等級與大小(cm^2)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Condition.code	required	ReferralConditionCrushVSTWLTC (a valid code from 轉介單壓傷狀況代碼) http://ltc-ig.fhir.tw/ValueSet/ReferralConditionCrushVS-TWLTC from this IG

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	TWCoreCondition	有關病情、問題或診斷的詳細資訊 con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
implicitRules	?!Σ	0..1	uri	創建此內容所依據的一組規則
modifierExtension	?!	0..*	Extension	此擴充的資料項目可能會完全修正或改變其他資料項目的意涵，需特別留意。
clinicalStatus	S	1..1	CodeableConceptTW	active | recurrence | relapse | inactive | remission | resolved ，病情、問題或診斷的臨床狀態。 Binding: ConditionClinicalStatusCodes (required): 應填入所綁定值集中的其中一個代碼。
verificationStatus	S	0..1	CodeableConceptTW	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error ，支持或拒絕病情、問題或診斷的臨床狀態的驗證狀態。 Binding: ConditionVerificationStatus (required): 應填入所綁定值集中的其中一個代碼。
category	S	1..1	CodeableConceptTW	problem-list-item | encounter-diagnosis ，指定病情、問題或診斷的類別。 Binding: ConditionCategoryCodes (extensible): 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。
severity	S	0..1	CodeableConceptTW	病情、問題或診斷的主觀嚴重程度 Binding: Condition/DiagnosisSeverity (extensible): 臨床醫生對病情、問題或診斷嚴重程度的主觀評價；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。
code	S	1..1	CodeableConceptTW	壓傷狀況 Binding: 壓傷狀況值集 (required)
Slices for coding	S	1..1	CodingTW	壓傷狀況代碼 Slice: Unordered, Open by pattern:$this
coding:All Slices				Content/Rules for all slices
system	SΣ	1..1	uri	專門術語系統（terminology system）的識別 Required Pattern: http://ltc-ig.fhir.tw/ValueSet/ReferralConditionCrushVS-TWLTC
code	SΣ	1..1	code	個案是否有壓傷？如果代碼為 crush，則需填寫備註以描述壓傷狀況
display	SΣ	0..1	string	由系統定義的表示法
coding:icd10-cm-2021	S	0..1	CodingTW	此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼，涵蓋範圍相對完整，可免費使用，可優先選用此代碼。 Binding: 臺灣健保署2021年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別；應填入所綁定值集中的其中一個代碼。
coding:icd10-cm-2014	S	0..1	CodingTW	此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼，涵蓋範圍相對完整，可免費使用，可優先選用此代碼。 Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別；應填入所綁定值集中的其中一個代碼。
coding:icd9-cm-2001	S	0..1	CodingTW	由專門術語系統（terminology system）定義的代碼 Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required)
coding:absentOrUnknownProblem	S	0..1	CodingTW	不存在的問題或未知問題的代碼 Binding: Absent or Unknown Problems - IPS (required): 應填入所綁定值集中的其中一個代碼。
coding:sct	S	0..1	CodingTW	此為SNOMED CT診斷代碼，若機構已有購買相關授權，亦可使用。 Binding: SNOMED CT診斷代碼值集 (required): 應填入所綁定值集中的其中一個代碼。
text	SΣ	0..1	string	概念的文字表示法
bodySite	S	0..*	CodeableConceptTW	如果相關請填寫解剖位置 Binding: SNOMEDCTBodyStructures (extensible): 描述解剖位置的代碼。可包括側面；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。
subject	SΣ	1..1	Reference(TW Core Patient | Group)	誰有此病情、問題或診斷？
onset[x]	SΣ	0..1		估計的或實際的日期、日期—時間或年齡。
onsetDateTime			dateTime
abatement[x]	SC	0..1		何時解決/緩解
abatementDateTime			dateTime
asserter	SΣ	0..1	Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | RelatedPerson)	聲稱有此病情、問題或診斷的人
note	S	0..1	Annotation	壓傷狀況與類別備註，應填寫部位、等級與大小(cm^2)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard
Condition.category	extensible	ConditionCategoryCodes http://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard
Condition.severity	extensible	Condition/DiagnosisSeverity http://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard
Condition.code	required	ReferralConditionCrushVSTWLTC (a valid code from 轉介單壓傷狀況代碼) http://ltc-ig.fhir.tw/ValueSet/ReferralConditionCrushVS-TWLTC from this IG
Condition.code.coding:icd10-cm-2021	required	TW2021ICD10CM https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2021-tw
Condition.code.coding:icd10-cm-2014	required	TW2014ICD10CM https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2014-tw
Condition.code.coding:icd9-cm-2001	required	TW2001ICD9CM https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw
Condition.code.coding:absentOrUnknownProblem	required	AbsentOrUnknownProblemsUvIps http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips
Condition.code.coding:sct	required	TWConditionCodeSCT https://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw
Condition.bodySite	extensible	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
con-3	best practice	Condition	Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4	error	Condition	If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5	error	Condition	Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2	error	Condition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Condition	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	Condition	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	Condition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Condition	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()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	TWCoreCondition	有關病情、問題或診斷的詳細資訊 con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
id	Σ	0..1	id	不重複的ID用以識別儲存在特定FHIR Server中的Condition紀錄，通常又稱為邏輯性ID。
meta	Σ	0..1	Meta	此Condition Resource的metadata
implicitRules	?!Σ	0..1	uri	創建此內容所依據的一組規則
language		0..1	code	用以表述Condition Resource內容的語言。 Binding: CommonLanguages (preferred): 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。 Additional Bindings Purpose AllLanguages Max Binding Example Value: zh-TW
text		0..1	Narrative	Condition Resource之內容摘要以供人閱讀
contained		0..*	Resource	內嵌的（contained）、行內的Resources
extension		0..*	Extension	擴充的資料項目
modifierExtension	?!	0..*	Extension	此擴充的資料項目可能會完全修正或改變其他資料項目的意涵，需特別留意。
identifier	Σ	0..*	Identifier	此病情、問題或診斷的外部識別碼
clinicalStatus	S	1..1	CodeableConceptTW	active | recurrence | relapse | inactive | remission | resolved ，病情、問題或診斷的臨床狀態。 Binding: ConditionClinicalStatusCodes (required): 應填入所綁定值集中的其中一個代碼。
verificationStatus	S	0..1	CodeableConceptTW	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error ，支持或拒絕病情、問題或診斷的臨床狀態的驗證狀態。 Binding: ConditionVerificationStatus (required): 應填入所綁定值集中的其中一個代碼。
category	S	1..1	CodeableConceptTW	problem-list-item | encounter-diagnosis ，指定病情、問題或診斷的類別。 Binding: ConditionCategoryCodes (extensible): 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。
severity	S	0..1	CodeableConceptTW	病情、問題或診斷的主觀嚴重程度 Binding: Condition/DiagnosisSeverity (extensible): 臨床醫生對病情、問題或診斷嚴重程度的主觀評價；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。
code	S	1..1	CodeableConceptTW	壓傷狀況 Binding: 壓傷狀況值集 (required)
id		0..1	string	唯一可識別ID，以供資料項目間相互參照。
extension		0..*	Extension	擴充的資料項目 Slice: Unordered, Open by value:url
Slices for coding	S	1..1	CodingTW	壓傷狀況代碼 Slice: Unordered, Open by pattern:$this
coding:All Slices				Content/Rules for all slices
id		0..1	string	唯一可識別ID，以供資料項目間相互參照。
extension		0..*	Extension	擴充的資料項目 Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	專門術語系統（terminology system）的識別 Required Pattern: http://ltc-ig.fhir.tw/ValueSet/ReferralConditionCrushVS-TWLTC
version	Σ	0..1	string	系統的版本—如果相關的話
code	SΣ	1..1	code	個案是否有壓傷？如果代碼為 crush，則需填寫備註以描述壓傷狀況
display	SΣ	0..1	string	由系統定義的表示法
userSelected	Σ	0..1	boolean	此編碼是否由使用者直接選擇？
coding:icd10-cm-2021	S	0..1	CodingTW	此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼，涵蓋範圍相對完整，可免費使用，可優先選用此代碼。 Binding: 臺灣健保署2021年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別；應填入所綁定值集中的其中一個代碼。
coding:icd10-cm-2014	S	0..1	CodingTW	此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼，涵蓋範圍相對完整，可免費使用，可優先選用此代碼。 Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別；應填入所綁定值集中的其中一個代碼。
coding:icd9-cm-2001	S	0..1	CodingTW	由專門術語系統（terminology system）定義的代碼 Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required)
coding:absentOrUnknownProblem	S	0..1	CodingTW	不存在的問題或未知問題的代碼 Binding: Absent or Unknown Problems - IPS (required): 應填入所綁定值集中的其中一個代碼。
coding:sct	S	0..1	CodingTW	此為SNOMED CT診斷代碼，若機構已有購買相關授權，亦可使用。 Binding: SNOMED CT診斷代碼值集 (required): 應填入所綁定值集中的其中一個代碼。
text	SΣ	0..1	string	概念的文字表示法
bodySite	S	0..*	CodeableConceptTW	如果相關請填寫解剖位置 Binding: SNOMEDCTBodyStructures (extensible): 描述解剖位置的代碼。可包括側面；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。
subject	SΣ	1..1	Reference(TW Core Patient | Group)	誰有此病情、問題或診斷？
encounter	Σ	0..1	Reference(TW Core Encounter)	作為病情、問題或診斷紀錄的一部分的就醫（Encounter）紀錄
onset[x]	SΣ	0..1		估計的或實際的日期、日期—時間或年齡。
onsetDateTime			dateTime S
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
abatement[x]	SC	0..1		何時解決/緩解
abatementDateTime			dateTime S
abatementAge			Age
abatementPeriod			Period
abatementRange			Range
abatementString			string
recordedDate	Σ	0..1	dateTime	記錄的日期
recorder	Σ	0..1	Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | RelatedPerson)	誰記錄此病情、問題或診斷
asserter	SΣ	0..1	Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | RelatedPerson)	聲稱有此病情、問題或診斷的人
stage	C	0..*	BackboneElement	分期（stage）／分級（grade），通常是正式的評估。 con-1: Stage SHALL have summary or assessment
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
summary		0..1	CodeableConceptTW	簡單的摘要（特定疾病）。 Binding: ConditionStage (extensible): 描述病情、問題或診斷分期的代碼（例如：癌症分期）。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。
assessment	C	0..*	Reference(ClinicalImpression | TW Core DiagnosticReport | TW Core Observation Laboratory Result | TW Core Observation Vital Signs)	正式的評估記錄
type		0..1	CodeableConceptTW	分期的種類 Binding: ConditionStageType (extensible): 病情、問題或診斷分期種類的代碼（如臨床或病理）；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。
evidence	C	0..*	BackboneElement	支持的證據 con-2: evidence SHALL have code or details
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		0..*	CodeableConceptTW	表現／症狀 Binding: ManifestationAndSymptomCodes (extensible): 病情、問題或診斷的表現或症狀之代碼；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。
detail	ΣC	0..*	Reference(Resource)	在其他地方找到的支持資訊
note	S	0..1	Annotation	壓傷狀況與類別備註，應填寫部位、等級與大小(cm^2)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Condition.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard
Condition.category	extensible	ConditionCategoryCodes http://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard
Condition.severity	extensible	Condition/DiagnosisSeverity http://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard
Condition.code	required	ReferralConditionCrushVSTWLTC (a valid code from 轉介單壓傷狀況代碼) http://ltc-ig.fhir.tw/ValueSet/ReferralConditionCrushVS-TWLTC from this IG
Condition.code.coding:icd10-cm-2021	required	TW2021ICD10CM https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2021-tw
Condition.code.coding:icd10-cm-2014	required	TW2014ICD10CM https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2014-tw
Condition.code.coding:icd9-cm-2001	required	TW2001ICD9CM https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw
Condition.code.coding:absentOrUnknownProblem	required	AbsentOrUnknownProblemsUvIps http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips
Condition.code.coding:sct	required	TWConditionCodeSCT https://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw
Condition.bodySite	extensible	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Condition.stage.summary	extensible	ConditionStage http://hl7.org/fhir/ValueSet/condition-stage from the FHIR Standard
Condition.stage.type	extensible	ConditionStageType http://hl7.org/fhir/ValueSet/condition-stage-type from the FHIR Standard
Condition.evidence.code	extensible	ManifestationAndSymptomCodes http://hl7.org/fhir/ValueSet/manifestation-or-symptom from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
con-1	error	Condition.stage	Stage SHALL have summary or assessment : summary.exists() or assessment.exists()
con-2	error	Condition.evidence	evidence SHALL have code or details : code.exists() or detail.exists()
con-3	best practice	Condition	Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4	error	Condition	If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5	error	Condition	Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2	error	Condition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Condition	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	Condition	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	Condition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Condition	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 TWCoreCondition

Summary

Mandatory: 4 elements

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