臺灣長期照顧實作指引 (Taiwan Long-Term Care Implementation Guide)
0.2.0 - ci-build+trial-use

臺灣長期照顧實作指引 (Taiwan Long-Term Care Implementation Guide) - Local Development build (v0.2.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: LTCObservationVitalSigns - Detailed Descriptions

Active as of 2024-10-23

Definitions for the LTCObservationVitalSigns resource profile.

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

0. Observation
2. Observation.code
Short量測的生命體徵項目
4. Observation.subject
Short此生命體徵資料的量測對象
6. Observation.value[x]
Short生命體徵量測值
[x] NoteSeeChoice of Data Typesfor further information about how to use [x]

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

0. Observation
Definition

對病人、設備或其他對象進行的測量和簡單判定。


Measurements and simple assertions made about a patient, device or other subject.

Short檢驗檢查,測量及簡單的判定。Measurements and simple assertions
Comments

Used for simple observations such as device measurements, laboratory atomic results, vital signs, height, weight, smoking status, comments, etc. Other resources are used to provide context for observations such as laboratory reports, etc.

Control0..*
Is Modifierfalse
Summaryfalse
Alternate NamesVital Signs, Measurement, Results, Tests
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present (dataAbsentReason.empty() or value.empty())
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present (value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty())
vs-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present. ((component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()))
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present (dataAbsentReason.empty() or value.empty())
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present (value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty())
2. Observation.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.

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

ShortExtensions 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.

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


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

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
6. Observation.status
Definition

結果值的狀態


The status of the result value.

Shortregistered | preliminary | final | amended +registered | preliminary | final | amended +
Comments

這個資料項目被標記為修飾語/修飾用,因為附加到其他文件上的文件,其本身是不完整的文件。


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

Control1..1
BindingThe codes SHALL be taken from ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1
(required to http://hl7.org/fhir/ValueSet/observation-status|4.0.1)

檢驗檢查的狀態代碼;應填入所綁定值集中的其中一個代碼。


Codes providing the status of an observation.

Typecode
Is Modifiertrue because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

需要追踪單個結果狀態,有些結果在整個報告確定之前就已經確定了。


Need to track the status of individual results. Some results are finalized before the whole report is finalized.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. Observation.category
Definition

可以正式參照一個專門術語或本體論來定義一個概念,或者也可以文字表述此概念。


A code that classifies the general type of observation being made.

Short概念(concept)-參照一個專門術語或只是純文字。Classification of type of observation
Comments

並非所有的專門術語使用都符合這個一般模式。在某些情況下,資料模型不應該使用CodeableConcept而應直接使用Coding,並提供他們自己的結構來管理text、codings、translation、資料項目之間的關係、以及先組合配對/前組合式(pre-coordination)和後組合配對/後組合式(post-coordination)。


In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set.

Control10..*
BindingThe codes SHOULD be taken from ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category
(preferred to http://hl7.org/fhir/ValueSet/observation-category)

高層次的檢驗檢查分類;鼓勵使用所綁定值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。


Codes for high level observation categories.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

用於篩選取得及顯示之檢驗檢查


Used for filtering what observations are retrieved and displayed.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Observation.category. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ coding.code
  • value @ coding.system
  • 10. Observation.category:VSCat
    Slice NameVSCat
    Definition

    可以正式參照一個專門術語或本體論來定義一個概念,或者也可以文字表述此概念。


    A code that classifies the general type of observation being made.

    Short檢驗檢查分類Classification of type of observation
    Comments

    並非所有的專門術語使用都符合這個一般模式。在某些情況下,資料模型不應該使用CodeableConcept而應直接使用Coding,並提供他們自己的結構來管理text、codings、translation、資料項目之間的關係、以及先組合配對/前組合式(pre-coordination)和後組合配對/後組合式(post-coordination)。


    In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set.

    Control10..1*
    This element is affected by the following invariants: ele-1
    BindingThe codes SHOULD be taken from ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category
    (preferred to http://hl7.org/fhir/ValueSet/observation-category)

    高層次的檢驗檢查分類;鼓勵使用所綁定值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。


    Codes for high level observation categories.

    TypeCodeableConcept(TW CodeableConcept)
    Is Modifierfalse
    Must Supporttrue
    Requirements

    用於篩選取得及顯示之檢驗檢查


    Used for filtering what observations are retrieved and displayed.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    12. Observation.category:VSCat.coding
    Definition

    由專門術語系統(terminology system)所定義之代碼的參照。


    A reference to a code defined by a terminology system.

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

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


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

    Control10..*
    TypeCoding
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Requirements

    允許使用者在不知道識別碼系統的情況下利用識別碼


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

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    14. Observation.category:VSCat.coding.system
    Definition

    定義代碼中符號意義的代碼系統識別。


    The identification of the code system that defines the meaning of the symbol in the code.

    Short專門術語系統(terminology system)的識別Identity of the terminology system
    Comments

    URI可以是一個OID(urn:oid:...)或一個UUID(urn:uuid:...);OID和UUID 必須(SHALL) 參照HL7 OID註冊中心;否則,URI應該來自HL7的FHIR定義的特殊URI列表,或者它應該參照一些明確建立的系统定義。


    The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

    Control10..1
    Typeuri
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Requirements

    需要明確說明符號定義的來源


    Need to be unambiguous about the source of the definition of the symbol.

    Fixed Valuehttp://terminology.hl7.org/CodeSystem/observation-category
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    16. Observation.category:VSCat.coding.code
    Definition

    系統定義的語法之符號;符號可能是一個預先定義的代碼,也可能是代碼系統定義的語法中的表達式(如後組合配對/後組合式)。


    A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

    Short系統定義的語法之符號Symbol in syntax defined by the system
    Control10..1
    Typecode
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Requirements

    需要參照系統中的一個特定代碼


    Need to refer to a particular code in the system.

    Fixed Valuevital-signs
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    18. Observation.code
    Definition

    可以透過正式參照一個專門術語或本體論來定義一個概念,或者也可以文字表述此概念。


    Describes what was observed. Sometimes this is called the observation "name".

    Short量測的生命體徵項目Type of observation (code / type)
    Comments

    並非所有的專門術語使用都符合這個一般模式。在某些情況下,資料模型不應該使用CodeableConcept而應直接使用Coding,並提供他們自己的結構來管理text、codings、translation、資料項目之間的關係、以及先組合配對/前組合式(pre-coordination)和後組合配對/後組合式(post-coordination)。


    All code-value and, if present, component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.

    Control1..1
    This element is affected by the following invariants: ele-1
    BindingUnless not suitable, these codes SHALL be taken from For example codes, see 生命體徵值集http://hl7.org/fhir/ValueSet/observation-codes
    (extensible to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/vital-signs-tw)

    應填入所綁定值集中的其中一個代碼。


    Codes identifying names of simple observations.

    TypeCodeableConcept(TW CodeableConcept)
    Is Modifierfalse
    Must Supporttrue
    Requirements

    知道正在進行的是哪種檢驗檢查是理解檢驗檢查的關鍵


    Knowing what kind of observation is being made is essential to understanding the observation.

    Alternate NamesName
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    20. Observation.code.coding
    Definition

    由專門術語系統(terminology system)所定義之代碼的參照


    A reference to a code defined by a terminology system.

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

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


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

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

    允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。


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

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

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


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

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

    很多時候,此文字表述與其中一個代碼的顯示名稱相同。


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

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

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


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

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

    此檢驗檢查是關於一位病人、一群病人、地點、或設備。如果檢驗檢查的實際焦點與對象(或其樣本、其部分或其區域)不同,則焦點資料項目或代碼本身會具體說明檢驗檢查的實際焦點。


    The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the focus element or the code itself specifies the actual focus of the observation.

    Short此生命體徵資料的量測對象Who and/or what the observation is about
    Comments

    人們期望這個資料項目的cardinality為1...1。唯一可能缺少對象的情況是當檢驗檢查是由一個不認識病人的設備進行的。在這種情況下,應透過一些情境/通道對應(context/channel matching)技術將檢驗檢查與病人對應,此時,應更新檢驗檢查資訊。


    One would expect this element to be a cardinality of 1..1. The only circumstance in which the subject can be missing is when the observation is made by a device that does not know the patient. In this case, the observation SHALL be matched to a patient through some context/channel matching technique, and at this point, the observation should be updated.

    Control10..1
    TypeReference(TW Core Patient, Patient, Group, Device, Location)
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Requirements

    如果你不知道他們是誰或關於什麼,檢驗檢查不會有值。


    Observations have no value if you don't know who or what they're about.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    26. Observation.effective[x]
    Definition

    宣告檢驗檢查值的產出時間或時間區段是真的。對於生物學研究對象—例如病人—這通常被稱為「生理相關時間」。這通常是處置的時間或採樣的時間,但很多時候不知道日期或時間的來源,只知道日期或時間本身。


    The time or time-period the observed value is asserted as being true. For biological subjects - e.g. human patients - this is usually called the "physiologically relevant time". This is usually either the time of the procedure or of specimen collection, but very often the source of the date/time is not known, only the date/time itself.

    Short檢驗檢查執行日期或時間區間Clinically relevant time/time-period for observation
    Comments

    除非這是一份檢驗檢查的歷史報告,否則至少應該有一個日期。為了記錄不精確或「模煳」的時間(例如:測量「早餐後 」血糖),使用Timing datatype以允許測量能與常規生活事件連結。


    At least a date should be present unless this observation is a historical report. For recording imprecise or "fuzzy" times (For example, a blood glucose measurement taken "after breakfast") use the Timing datatype which allow the measurement to be tied to regular life events.

    Control10..1
    This element is affected by the following invariants: vs-1
    TypeChoice of: dateTime, Period, Timing, instant
    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Must Support TypesdateTime
    Summarytrue
    Requirements

    知道一項檢驗檢查何時被認為是真的,對其相關性和確定趨勢都很重要。


    Knowing when an observation was deemed true is important to its relevance as well as determining trends.

    Alternate NamesOccurrence
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    vs-1: if Observation.effective[x] is dateTime and has a value then that value shall be precise to the day ($this is dateTime implies $this.toString().length() >= 10)
    28. Observation.performer
    Definition

    誰負責宣告檢驗檢查結果值為「真的」


    Who was responsible for asserting the observed value as "true".

    Short誰負責這項檢驗檢查Who is responsible for the observation
    Control0..*
    TypeReference(TW Core Practitioner, TW Core Organization, TW Core Patient, TW Core PractitionerRole, TW Core CareTeam, Practitioner, PractitionerRole, Organization, CareTeam, Patient, RelatedPerson)
    Is Modifierfalse
    Must Supporttrue
    Must Support TypesNo must-support rules about the choice of types/profiles
    Summarytrue
    Requirements

    可以對此檢驗檢查有一定程度的信任,並指出後續問題的方向。


    May give a degree of confidence in the observation and also indicates where follow-up questions should be directed.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    30. Observation.value[x]
    Definition

    如果此資訊有一個簡單的值,則將其作為此項檢驗檢查的結果。


    The information determined as a result of making the observation, if the information has a simple value.

    Short生命體徵量測值Actual result
    Comments

    一項檢驗檢查可能有:1)單一值、2)一個值及一組相關或組成之檢驗檢查的多個值、或者3)只有一組相關或組成之檢驗檢查的多個值。如果有一個值,這個資料項目的datatype應該由Observation.code決定。如果這個資料項目是編碼或者如果與Observation.code相關的type定義一個編碼值,那麼將使用只有文字表述的CodeableConcept來代替字串。若需要更多的說明,請參閱下面Notes小節。


    An observation may have; 1) a single value here, 2) both a value and a set of related or component values, or 3) only a set of related or component values. If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the Notes section below.

    Control0..1
    This element is affected by the following invariants: obs-7, vs-2
    BindingUnless not suitable, these codes SHALL be taken from For codes, see VitalSignsUnits
    (extensible to http://hl7.org/fhir/ValueSet/ucum-vitals-common)

    用於記錄生命體徵的常用UCUM單元;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。

    TypeChoice of: Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period
    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Must Support TypesQuantity
    Summarytrue
    Requirements

    通常一項檢驗檢查就會有一個值,雖然若它有錯誤或者它代表一組檢驗檢查可能不會有值。


    An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    32. Observation.dataAbsentReason
    Definition

    提供資料項目Observation.value[x]中的預期值缺少的原因


    Provides a reason why the expected value in the element Observation.value[x] is missing.

    Short缺少檢驗檢查結果的原因Why the result is missing
    Comments

    空值(Null)或例外值可以在FHIR Observations中以兩種方式表示,一種方法是簡單地將它們含括在值集中,並在值中表示例外。例如:血清檢測的測量值可以是「檢測到」、「未檢測到」、「不確定」或「檢測未完成」。

    另一種方法是使用資料項目value呈現實際檢驗檢查值,並使用資料項目dataAbsentReason來明確記錄例外值。例如:當測量沒有完成,可使用dataAbsentReason代碼「error」。請注意,只有在有值的情況下,才可以報告檢驗檢查。例如:只有在>0的情況下才可能報告細胞計數的差值。由於有這些選項,所以需要有使用案例協議(use-case agreements)來解釋一般檢驗檢查的例外值。


    Null or exceptional values can be represented two ways in FHIR Observations. One way is to simply include them in the value set and represent the exceptions in the value. For example, measurement values for a serology test could be "detected", "not detected", "inconclusive", or "specimen unsatisfactory".

    The alternate way is to use the value element for actual observations and use the explicit dataAbsentReason element to record exceptional values. For example, the dataAbsentReason code "error" could be used when the measurement was not completed. Note that an observation may only be reported if there are values to report. For example differential cell counts values may be reported only when > 0. Because of these options, use-case agreements are required to interpret general observations for null or exceptional values.

    Control0..1
    This element is affected by the following invariants: ele-1, obs-6
    BindingUnless not suitable, these codes SHALL be taken from DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason
    (extensible to http://hl7.org/fhir/ValueSet/data-absent-reason)

    代碼具體說明檢驗檢查結果缺少的原因;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 specifying why the result (Observation.value[x]) is missing.

    TypeCodeableConcept(TW CodeableConcept)
    Is Modifierfalse
    Must Supporttrue
    Requirements

    對於許多結果,必須處理測量中的異常值。


    For many results it is necessary to handle exceptional values in measurements.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    34. Observation.component
    Definition

    有有些檢驗檢查有多個組成之檢驗檢查,這些組成之檢驗檢查被表達為具有相同屬性的獨立的代碼值對(code value pair)。例子包括血壓測量的收縮壓和舒張壓即為組成之檢驗檢查(component observations),以及遺傳學檢驗檢查的多個組成之檢驗檢查。


    Some observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes. Examples include systolic and diastolic component observations for blood pressure measurement and multiple component observations for genetics observations.

    Short組成之(部分)檢驗檢查的檢驗結果Component results
    Comments

    有關如何組合Observations的方法討論,請參閱下面的Notes小節。


    For a discussion on the ways Observations can be assembled in groups together see Notes below.

    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Requirements

    組成之檢驗檢查在Obsrvation resource中與主要檢驗檢查共享相同的屬性,並且總是被視為單個檢驗檢查的一部分(它們是不可分離的)。然而,主要檢驗檢查的參考範圍值並不被組成之檢驗檢查所繼承,在適當的時候需給予每項組成之檢驗檢查參考範圍值。


    Component observations share the same attributes in the Observation resource as the primary observation and are always treated a part of a single observation (they are not separable). However, the reference range for the primary observation value is not inherited by the component values and is required when appropriate for each component observation.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    vs-3: If there is no a value a data absent reason must be present (value.exists() or dataAbsentReason.exists())
    36. Observation.component.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).

    ShortExtensions 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.

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


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

    Alternate Namesextensions, user content, modifiers
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    38. Observation.component.code
    Definition

    描述所觀察到的情況,有時這被稱為檢驗檢查「代碼」。


    Describes what was observed. Sometimes this is called the observation "code".

    Short組成之檢驗檢查的型別(代碼/型別)Type of component observation (code / type)
    Comments

    所有的code-value和component.code-component.value都需要考慮到,以正確理解檢驗檢查的意義。


    All code-value and component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.

    Control1..1
    This element is affected by the following invariants: ele-1
    BindingUnless not suitable, these codes SHALL be taken from For example codes, see 生命體徵值集http://hl7.org/fhir/ValueSet/observation-codes
    (extensible to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/vital-signs-tw)

    代碼指明檢驗檢查的名稱;可參考所綁定值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。


    Codes identifying names of simple observations.

    TypeCodeableConcept(TW CodeableConcept)
    Is Modifierfalse
    Must Supporttrue
    Requirements

    知道正在進行的是哪種檢驗檢查是理解檢驗檢查的關鍵


    Knowing what kind of observation is being made is essential to understanding the observation.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    40. Observation.component.value[x]
    Definition

    Vital Sign Value recorded with UCUM.


    The information determined as a result of making the observation, if the information has a simple value.

    ShortVital Sign Value recorded with UCUMActual component result
    Comments

    Used when observation has a set of component observations. An observation may have both a value (e.g. an Apgar score) and component observations (the observations from which the Apgar score was derived). If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the Notes section below.


    Used when observation has a set of component observations. An observation may have both a value (e.g. an Apgar score) and component observations (the observations from which the Apgar score was derived). If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the Notes section below.

    Control0..1
    This element is affected by the following invariants: vs-3
    BindingUnless not suitable, these codes SHALL be taken from For codes, see VitalSignsUnits
    (extensible to http://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1)

    Common UCUM units for recording Vital Signs.

    TypeChoice of: Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period
    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Must Support TypesQuantity
    Summarytrue
    Requirements
    1. SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:7305).

    An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    42. Observation.component.dataAbsentReason
    Definition

    提供資料項目Observation.component.value[x]中的預期值缺少的原因


    Provides a reason why the expected value in the element Observation.component.value[x] is missing.

    Short為什麼缺少組成之檢驗檢查結果Why the component result is missing
    Comments

    空值(Null)或例外值可以在FHIR Observations中以兩種方式表示,一種方法是簡單地將它們含括在值集中,並在值中表示例外。例如:血清檢測的測量值可以是「檢測到」、「未檢測到」、「不確定」或「檢測未完成」。

    另一種方法是使用資料項目value呈現實際檢驗檢查值,並使用資料項目dataAbsentReason來明確記錄例外值。例如:當測量沒有完成,可使用dataAbsentReason代碼「error」。請注意,只有在有值的情況下,才可以報告檢驗檢查。例如:只有在>0的情況下才可能報告細胞計數的差值。由於有這些選項,所以需要有使用案例協議(use-case agreements)來解釋一般檢驗檢查的例外值。


    "Null" or exceptional values can be represented two ways in FHIR Observations. One way is to simply include them in the value set and represent the exceptions in the value. For example, measurement values for a serology test could be "detected", "not detected", "inconclusive", or "test not done".

    The alternate way is to use the value element for actual observations and use the explicit dataAbsentReason element to record exceptional values. For example, the dataAbsentReason code "error" could be used when the measurement was not completed. Because of these options, use-case agreements are required to interpret general observations for exceptional values.

    Control0..1
    This element is affected by the following invariants: ele-1, obs-6
    BindingUnless not suitable, these codes SHALL be taken from DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason
    (extensible to http://hl7.org/fhir/ValueSet/data-absent-reason)

    代碼指明為什麼結果(Observation.value[x])缺少;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 specifying why the result (Observation.value[x]) is missing.

    TypeCodeableConcept(TW CodeableConcept)
    Is Modifierfalse
    Must Supporttrue
    Requirements

    對於許多結果,必須處理測量中的異常值。


    For many results it is necessary to handle exceptional values in measurements.

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

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

    0. Observation
    Definition

    對病人、設備或其他對象進行的測量和簡單判定。

    Short檢驗檢查,測量及簡單的判定。
    Comments

    Used for simple observations such as device measurements, laboratory atomic results, vital signs, height, weight, smoking status, comments, etc. Other resources are used to provide context for observations such as laboratory reports, etc.

    Control0..*
    Is Modifierfalse
    Summaryfalse
    Alternate NamesVital Signs, Measurement, Results, Tests
    Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
    dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
    dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
    dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
    dom-6: A resource should have narrative for robust management (text.`div`.exists())
    obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present (dataAbsentReason.empty() or value.empty())
    obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present (value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty())
    vs-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present. ((component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()))
    2. Observation.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Observation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。

    Control0..1
    Typeid
    Is Modifierfalse
    Summarytrue
    4. Observation.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Observation Resource的metadata
    Control0..1
    TypeMeta
    Is Modifierfalse
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    6. Observation.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。

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

    編寫此resource的語言

    Short用以表述Observation 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)。

    Control0..1
    BindingThe 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。

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

    ShortObservation 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。

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

    ShortContained, 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.

    Control0..*
    TypeResource
    Is Modifierfalse
    Summaryfalse
    Alternate Namesinline resources, anonymous resources, contained resources
    14. Observation.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.

    ShortAdditional 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.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    16. Observation.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).

    ShortExtensions 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.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
    Summaryfalse
    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 Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    18. Observation.identifier
    Definition

    此檢驗檢查的唯一識別碼

    Short檢驗檢查的識別碼,通常為業務目的所使用的識別碼,例如:檢驗序號或單號。
    NoteThis is a business identifier, not a resource identifier (see discussion)
    Control0..*
    TypeIdentifier
    Is Modifierfalse
    Summarytrue
    Requirements

    允許對檢驗檢查結果進行區分和參照

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

    依據的計劃、提議或醫令或其部分要求進行檢驗檢查。例如:一個MedicationRequest可能要求給病人藥之前要先進行實驗室檢查。

    Short依據的照護計畫/提議/醫令
    Control0..*
    TypeReference(CarePlan, DeviceRequest, ImmunizationRecommendation, TW Core MedicationRequest, NutritionOrder, TW Core ServiceRequest)
    Is Modifierfalse
    Summarytrue
    Requirements

    允許授權追踪檢驗檢查事件並追踪提議/建議是否有落實

    Alternate NamesFulfills
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    22. Observation.partOf
    Definition

    此特定的檢驗檢查(Observation)是一個更大事件中的一個組成或步驟。例如:一項處置裡的一項檢驗檢查。

    Short此檢驗檢查是哪個參照事件的一部分
    Comments

    使用encounter將一個檢驗檢查(Observation)與一個就醫(Encounter)連結起來。關於參照另一個Observation的作法,請參閱下面的Notes小節。

    Control0..*
    TypeReference(MedicationAdministration, TW Core MedicationDispense, TW Core MedicationStatement, TW Core Procedure, TW Core Immunization, TW Core ImagingStudy)
    Is Modifierfalse
    Summarytrue
    Alternate NamesContainer
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    24. Observation.status
    Definition

    結果值的狀態

    Shortregistered | preliminary | final | amended +
    Comments

    這個資料項目被標記為修飾語/修飾用,因為附加到其他文件上的文件,其本身是不完整的文件。

    Control1..1
    BindingThe codes SHALL be taken from ObservationStatus
    (required to http://hl7.org/fhir/ValueSet/observation-status|4.0.1)

    檢驗檢查的狀態代碼;應填入所綁定值集中的其中一個代碼。

    Typecode
    Is Modifiertrue because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Requirements

    需要追踪單個結果狀態,有些結果在整個報告確定之前就已經確定了。

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    26. Observation.category
    Definition

    可以正式參照一個專門術語或本體論來定義一個概念,或者也可以文字表述此概念。

    Short概念(concept)-參照一個專門術語或只是純文字。
    Comments

    並非所有的專門術語使用都符合這個一般模式。在某些情況下,資料模型不應該使用CodeableConcept而應直接使用Coding,並提供他們自己的結構來管理text、codings、translation、資料項目之間的關係、以及先組合配對/前組合式(pre-coordination)和後組合配對/後組合式(post-coordination)。

    Control1..*
    BindingThe codes SHOULD be taken from ObservationCategoryCodes
    (preferred to http://hl7.org/fhir/ValueSet/observation-category)

    高層次的檢驗檢查分類;鼓勵使用所綁定值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。

    TypeCodeableConcept(TW CodeableConcept)
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Requirements

    用於篩選取得及顯示之檢驗檢查

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    SlicingThis element introduces a set of slices on Observation.category. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • value @ coding.code
    • value @ coding.system
    • 28. Observation.category:VSCat
      Slice NameVSCat
      Definition

      可以正式參照一個專門術語或本體論來定義一個概念,或者也可以文字表述此概念。

      Short檢驗檢查分類
      Comments

      並非所有的專門術語使用都符合這個一般模式。在某些情況下,資料模型不應該使用CodeableConcept而應直接使用Coding,並提供他們自己的結構來管理text、codings、translation、資料項目之間的關係、以及先組合配對/前組合式(pre-coordination)和後組合配對/後組合式(post-coordination)。

      Control1..1
      This element is affected by the following invariants: ele-1
      BindingThe codes SHOULD be taken from ObservationCategoryCodes
      (preferred to http://hl7.org/fhir/ValueSet/observation-category)

      高層次的檢驗檢查分類;鼓勵使用所綁定值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。

      TypeCodeableConcept(TW CodeableConcept)
      Is Modifierfalse
      Must Supporttrue
      Requirements

      用於篩選取得及顯示之檢驗檢查

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      30. Observation.category:VSCat.id
      Definition

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

      ShortUnique id for inter-element referencing
      Control0..1
      Typestring
      Is Modifierfalse
      XML FormatIn the XML format, this property is represented as an attribute.
      Summaryfalse
      32. Observation.category:VSCat.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.

      ShortAdditional 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.

      Control0..*
      TypeExtension
      Is Modifierfalse
      Summaryfalse
      Alternate Namesextensions, user content
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      SlicingThis element introduces a set of slices on Observation.category.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • value @ url
      • 34. Observation.category:VSCat.coding
        Definition

        由專門術語系統(terminology system)所定義之代碼的參照。

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

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

        Control1..*
        TypeCoding
        Is Modifierfalse
        Must Supporttrue
        Summarytrue
        Requirements

        允許使用者在不知道識別碼系統的情況下利用識別碼

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        36. Observation.category:VSCat.coding.id
        Definition

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

        ShortUnique id for inter-element referencing
        Control0..1
        Typestring
        Is Modifierfalse
        XML FormatIn the XML format, this property is represented as an attribute.
        Summaryfalse
        38. Observation.category:VSCat.coding.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.

        ShortAdditional 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.

        Control0..*
        TypeExtension
        Is Modifierfalse
        Summaryfalse
        Alternate Namesextensions, user content
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        SlicingThis element introduces a set of slices on Observation.category.coding.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
        • value @ url
        • 40. Observation.category:VSCat.coding.system
          Definition

          定義代碼中符號意義的代碼系統識別。

          Short專門術語系統(terminology system)的識別
          Comments

          URI可以是一個OID(urn:oid:...)或一個UUID(urn:uuid:...);OID和UUID 必須(SHALL) 參照HL7 OID註冊中心;否則,URI應該來自HL7的FHIR定義的特殊URI列表,或者它應該參照一些明確建立的系统定義。

          Control1..1
          Typeuri
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Must Supporttrue
          Summarytrue
          Requirements

          需要明確說明符號定義的來源

          Fixed Valuehttp://terminology.hl7.org/CodeSystem/observation-category
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          42. Observation.category:VSCat.coding.version
          Definition

          選擇此代碼時使用的代碼系統版本;請注意,一個維護良好的代碼系統不需要版本報告,因為代碼的意義在不同系統版本中是一致的;然而,不能始終保證這點,當不能保證意義一致時, 必須(SHALL) 將版本資訊也一併作交換。

          Short系統的版本—如果相關的話
          Comments

          如果專門術語沒有明確定義應該使用什麼字串來識別代碼系統的版本,建議使用版本正式發布的日期(用FHIR日期格式表示)作為版本日期。

          NoteThis is a business version Id, not a resource version Id (see discussion)
          Control0..1
          Typestring
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Summarytrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          44. Observation.category:VSCat.coding.code
          Definition

          系統定義的語法之符號;符號可能是一個預先定義的代碼,也可能是代碼系統定義的語法中的表達式(如後組合配對/後組合式)。

          Short系統定義的語法之符號
          Control1..1
          Typecode
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Must Supporttrue
          Summarytrue
          Requirements

          需要參照系統中的一個特定代碼

          Fixed Valuevital-signs
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          46. Observation.category:VSCat.coding.display
          Definition

          遵循系統的規則以呈現代碼含義的表示法

          Short由系統定義的表示法
          Control0..1
          Typestring
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Summarytrue
          Requirements

          需要能為不了解此系統的讀者呈現可讀的代碼含義

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          48. Observation.category:VSCat.coding.userSelected
          Definition

          表明此編碼是由使用者直接選擇,例如:從可用項目(代碼或顯示名稱)的清單中選擇。

          Short此編碼是否由使用者直接選擇?
          Comments

          在一系列備選方案中,直接選擇的代碼是新翻譯最合適的起點;關於「直接選擇」的確切意義,存在模糊不清之處,可能需要貿易夥伴的同意,以更完整澄清此資料項目的使用及其後果。

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

          已被確定為一個臨床安全準則—此確切的系統/代碼對(code pair)是被明確選擇的,而不是由系統根據一些規則或是程式語言處理判斷。

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          50. Observation.category:VSCat.text
          Definition

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

          Short概念的文字表示法
          Comments

          很多時候,此文字表述與其中一個代碼的顯示名稱相同。

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

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

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

          可以透過正式參照一個專門術語或本體論來定義一個概念,或者也可以文字表述此概念。

          Short量測的生命體徵項目
          Comments

          並非所有的專門術語使用都符合這個一般模式。在某些情況下,資料模型不應該使用CodeableConcept而應直接使用Coding,並提供他們自己的結構來管理text、codings、translation、資料項目之間的關係、以及先組合配對/前組合式(pre-coordination)和後組合配對/後組合式(post-coordination)。

          Control1..1
          This element is affected by the following invariants: ele-1
          BindingUnless not suitable, these codes SHALL be taken from 生命體徵值集
          (extensible to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/vital-signs-tw)

          應填入所綁定值集中的其中一個代碼。

          TypeCodeableConcept(TW CodeableConcept)
          Is Modifierfalse
          Must Supporttrue
          Requirements

          知道正在進行的是哪種檢驗檢查是理解檢驗檢查的關鍵

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

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

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

          擴充的資料項目

          Short擴充的資料項目
          Control0..*
          TypeExtension
          Is Modifierfalse
          Summaryfalse
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          SlicingThis element introduces a set of slices on Observation.code.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
          • value @ url
          • 58. Observation.code.coding
            Definition

            由專門術語系統(terminology system)所定義之代碼的參照

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

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

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

            允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。

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

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

            Short概念的文字表示法
            Comments

            很多時候,此文字表述與其中一個代碼的顯示名稱相同。

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

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

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

            此檢驗檢查是關於一位病人、一群病人、地點、或設備。如果檢驗檢查的實際焦點與對象(或其樣本、其部分或其區域)不同,則焦點資料項目或代碼本身會具體說明檢驗檢查的實際焦點。

            Short此生命體徵資料的量測對象
            Comments

            人們期望這個資料項目的cardinality為1...1。唯一可能缺少對象的情況是當檢驗檢查是由一個不認識病人的設備進行的。在這種情況下,應透過一些情境/通道對應(context/channel matching)技術將檢驗檢查與病人對應,此時,應更新檢驗檢查資訊。

            Control1..1
            TypeReference(TW Core Patient)
            Is Modifierfalse
            Must Supporttrue
            Summarytrue
            Requirements

            如果你不知道他們是誰或關於什麼,檢驗檢查不會有值。

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            64. Observation.focus
            Definition

            檢驗檢查的實際焦點,當它不是記錄病人時,代表是與病人有關的事物或人,如配偶、父母、胎兒或捐贈者。例如:母親的記錄中有關胎兒檢驗檢查。檢驗檢查的焦點也可以是現有的狀況、疾病或問題(condition)、介入(intervention)、此對象的飲食、對此對象的另一項檢驗檢查,或身體結構像是腫瘤或植入裝置。有一個案例是使用Observation Resource來取得母親是否已接受更換她的小孩的氣管插管訓練之資訊,在這個例子中,孩子是此記錄的病人,而母親是focus。

            Short當檢驗檢查並非有關於與病人本身,檢驗檢查是關於什麼。
            Comments

            通常檢驗檢查的對象是一位病人或一群病人、地點或設備,檢驗檢查對象與直接測量內容之間的區別在observation.code已具體說明(例如: 「血糖」),不需要使用這個資料項目(focus)單獨表示。如果需要參照檢體,則使用specimen,如果需要一個代碼而不是一個resource,則使用bodysite來表示bodysites或標準擴充focusCode。

            Control0..*
            TypeReference(Resource)
            Is Modifierfalse
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            66. Observation.encounter
            Definition

            執行檢驗檢查的健康照護事件(例如:病人及健康照護提供人員的互動)

            Short檢驗檢查是哪一次就醫時執行的
            Comments

            這通常指檢驗檢查發生於哪次就醫,但有些檢驗檢查可能是在就醫前或就醫後發生,但仍與就醫的情境有關(如入院前的實驗室檢驗檢查)。

            Control0..1
            TypeReference(TW Core Encounter)
            Is Modifierfalse
            Summarytrue
            Requirements

            對於某些檢驗檢查來說,知道某個檢驗檢查和某個特定的就醫事件之間的連結可能很重要。

            Alternate NamesContext
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            68. Observation.effective[x]
            Definition

            宣告檢驗檢查值的產出時間或時間區段是真的。對於生物學研究對象—例如病人—這通常被稱為「生理相關時間」。這通常是處置的時間或採樣的時間,但很多時候不知道日期或時間的來源,只知道日期或時間本身。

            Short檢驗檢查執行日期或時間區間
            Comments

            除非這是一份檢驗檢查的歷史報告,否則至少應該有一個日期。為了記錄不精確或「模煳」的時間(例如:測量「早餐後 」血糖),使用Timing datatype以允許測量能與常規生活事件連結。

            Control1..1
            This element is affected by the following invariants: vs-1
            TypeChoice of: dateTime, Period
            [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Must Supporttrue
            Must Support TypesdateTime
            Summarytrue
            Requirements

            知道一項檢驗檢查何時被認為是真的,對其相關性和確定趨勢都很重要。

            Alternate NamesOccurrence
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            vs-1: if Observation.effective[x] is dateTime and has a value then that value shall be precise to the day ($this is dateTime implies $this.toString().length() >= 10)
            70. Observation.issued
            Definition

            此版本的檢驗檢查資訊可供健康照護提供人員取得的日期和時間,通常是在結果被審查與核實之後。

            Short此版本檢驗檢查完成的日期或時間
            Comments

            對於不需要審查和核實的檢驗檢查值,發佈日期時間可能與resource本身的最後更新日期時間相同。對於需要對某些更新進行審查和核實的檢驗檢查,若為非臨床上的重要更新則不需要對新版本進行再次審查和驗證,所以發佈日期時間可能與resource本身的最後更新日期時間不一樣。

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

            誰負責宣告檢驗檢查結果值為「真的」

            Short誰負責這項檢驗檢查
            Control0..*
            TypeReference(TW Core Practitioner, TW Core Organization, TW Core Patient, TW Core PractitionerRole, TW Core CareTeam)
            Is Modifierfalse
            Must Supporttrue
            Must Support TypesNo must-support rules about the choice of types/profiles
            Summarytrue
            Requirements

            可以對此檢驗檢查有一定程度的信任,並指出後續問題的方向。

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            74. Observation.value[x]
            Definition

            如果此資訊有一個簡單的值,則將其作為此項檢驗檢查的結果。

            Short生命體徵量測值
            Comments

            一項檢驗檢查可能有:1)單一值、2)一個值及一組相關或組成之檢驗檢查的多個值、或者3)只有一組相關或組成之檢驗檢查的多個值。如果有一個值,這個資料項目的datatype應該由Observation.code決定。如果這個資料項目是編碼或者如果與Observation.code相關的type定義一個編碼值,那麼將使用只有文字表述的CodeableConcept來代替字串。若需要更多的說明,請參閱下面Notes小節。

            Control0..1
            This element is affected by the following invariants: obs-7, vs-2
            BindingUnless not suitable, these codes SHALL be taken from VitalSignsUnits
            (extensible to http://hl7.org/fhir/ValueSet/ucum-vitals-common)

            用於記錄生命體徵的常用UCUM單元;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。

            TypeChoice of: Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period
            [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Must Supporttrue
            Must Support TypesQuantity
            Summarytrue
            Requirements

            通常一項檢驗檢查就會有一個值,雖然若它有錯誤或者它代表一組檢驗檢查可能不會有值。

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

            提供資料項目Observation.value[x]中的預期值缺少的原因

            Short缺少檢驗檢查結果的原因
            Comments

            空值(Null)或例外值可以在FHIR Observations中以兩種方式表示,一種方法是簡單地將它們含括在值集中,並在值中表示例外。例如:血清檢測的測量值可以是「檢測到」、「未檢測到」、「不確定」或「檢測未完成」。

            另一種方法是使用資料項目value呈現實際檢驗檢查值,並使用資料項目dataAbsentReason來明確記錄例外值。例如:當測量沒有完成,可使用dataAbsentReason代碼「error」。請注意,只有在有值的情況下,才可以報告檢驗檢查。例如:只有在>0的情況下才可能報告細胞計數的差值。由於有這些選項,所以需要有使用案例協議(use-case agreements)來解釋一般檢驗檢查的例外值。

            Control0..1
            This element is affected by the following invariants: ele-1
            BindingUnless not suitable, these codes SHALL be taken from DataAbsentReason
            (extensible to http://hl7.org/fhir/ValueSet/data-absent-reason)

            代碼具體說明檢驗檢查結果缺少的原因;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。

            TypeCodeableConcept(TW CodeableConcept)
            Is Modifierfalse
            Must Supporttrue
            Requirements

            對於許多結果,必須處理測量中的異常值。

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

            對一項檢驗檢查值的分類評估,例如:高、低、正常。

            Short高、低、正常等
            Comments

            歷史上用於實驗室結果【被稱為 「異常標記(abnormal flag)」】,它的使用延伸到其他與編碼解釋有關的使用情況中。通常報告為一個或多個簡單的緊密碼(compact code,一種可以解譯且具有最小平均字長的唯一資料代碼),這個資料項目經常被放置在報告和流程表的結果值的旁邊,以表示結果的意義或正常狀態。

            Control0..*
            This element is affected by the following invariants: ele-1
            BindingUnless not suitable, these codes SHALL be taken from ObservationInterpretationCodes
            (extensible to http://hl7.org/fhir/ValueSet/observation-interpretation)

            代碼指明檢驗檢查結果的解釋;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。

            TypeCodeableConcept(TW CodeableConcept)
            Is Modifierfalse
            Requirements

            對於某些結果,特別是數值結果,需有一個解釋以便完全理解結果之意義。

            Alternate NamesAbnormal Flag
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            80. Observation.note
            Definition

            關於檢驗檢查或結果的解說

            Short關於此檢驗檢查之解說
            Comments

            可包括關於檢驗檢查的一般陳述,或關於重要的、非預期的或不可靠的結果值的陳述,或與資料項目interpretation有關的來源資訊。

            Control0..*
            TypeAnnotation
            Is Modifierfalse
            Summaryfalse
            Requirements

            需能提供純文字表述的附加資訊

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            82. Observation.bodySite
            Definition

            表示在檢驗檢查對象身上進行檢驗檢查的部位(即目標部位)

            Short接受檢驗檢查的身體部位。此為SNOMED CT代碼,若機構已有購買相關授權,亦可使用。
            Comments

            只有在Observation.code中的代碼未隱含時才會使用。在許多系統中,這可能被表示為一個相關的檢驗檢查,而不是一個行內的組成之檢驗檢查(inline component)。

            如果使用案例(use-case)要求將BodySite作為一個單獨的resource來處理(例如:單獨指明和追踪),那麼就使用標準的資料項目擴充方式來擴充bodySite。

            Control0..1
            This element is affected by the following invariants: ele-1
            BindingUnless not suitable, these codes SHALL be taken from SNOMEDCTBodyStructures
            (extensible to http://hl7.org/fhir/ValueSet/body-site)

            代碼說明解剖學位置,可能包含側邊;可參考所綁定值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。

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

            指明用於執行檢驗檢查的機制

            Short此檢驗檢查使用何種方法完成
            Comments

            只有在Observation.code中的代碼未隱含此資料項目概念時才會使用。

            Control0..1
            This element is affected by the following invariants: ele-1
            BindingUnless not suitable, these codes SHALL be taken from ObservationMethods
            (extensible to http://hl7.org/fhir/ValueSet/observation-methods)

            檢驗檢查的方法;可參考所綁定值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。

            TypeCodeableConcept(TW CodeableConcept)
            Is Modifierfalse
            Requirements

            在某些情況下,方法會影響結果,因此用於確認結果是否可以比較或確認結果的顯著性(significance)。

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            86. Observation.specimen
            Definition

            進行這項檢驗檢查時使用的檢體

            Short此檢驗檢查的檢體
            Comments

            只有在Observation.code中的代碼未隱含此資料項目概念時才會使用。 檢驗檢查不是針對檢體本身進行,而是針對對象,但在很多情況下是透過檢體的方式進行檢驗檢查。請注意,雖然經常涉及到檢體,但並不總是明確地對其進行追踪和報告。還要注意的是Observation resources可在明確追踪檢體的情境下使用(例如:Diagnostic Report)。

            Control0..1
            TypeReference(TW Core Specimen)
            Is Modifierfalse
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            88. Observation.device
            Definition

            用於產生檢驗檢查資料的設備

            Short(測量)設備
            Comments

            請注意,這不是用來表示結果傳輸的設備,例如:閘道器(gateway)等可在相關情況下使用 Provenance resource進行記錄。

            Control0..1
            TypeReference(Device, DeviceMetric)
            Is Modifierfalse
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            90. Observation.referenceRange
            Definition

            指導如何透過與正常或建議範圍值的比較來解釋此值。多個參考範圍值以「OR」解釋。換句話說,為了代表兩個不同的目標人群,將使用兩個referenceRange資料項目。

            Short解釋結果值的指引。 obs-3:必須至少有低、高或文字表述。
            Comments

            大多數檢驗檢查只有一個通用的參考範圍值。系統 可能可以(MAY) 選擇限制只提供病人的相關參考範圍值(例如:具體的病人年齡、性別、體重和其他因素),但這可能是不可能的或也不合適。只要提供了一個以上的參考範圍值,就 建議應該(SHOULD) 提供不同年齡的參考範圍值差異。

            Control0..*
            TypeBackboneElement
            Is Modifierfalse
            Summaryfalse
            Requirements

            知道什麼值被認為是「正常的」,可以幫助評估某一特定結果的意義。需要能夠為不同的情境提供多個參考範圍值。

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            obs-3: Must have at least a low or a high or text (low.exists() or high.exists() or text.exists())
            92. Observation.referenceRange.id
            Definition

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

            ShortUnique id for inter-element referencing
            Control0..1
            Typestring
            Is Modifierfalse
            XML FormatIn the XML format, this property is represented as an attribute.
            Summaryfalse
            94. Observation.referenceRange.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.

            ShortAdditional 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.

            Control0..*
            TypeExtension
            Is Modifierfalse
            Summaryfalse
            Alternate Namesextensions, user content
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            96. Observation.referenceRange.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).

            ShortExtensions 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.

            Control0..*
            TypeExtension
            Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
            Summarytrue
            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 Namesextensions, user content, modifiers
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            98. Observation.referenceRange.low
            Definition

            參考範圍值的下限值。參考範圍值endpoint的下限值包含在此值中(例如:參考範圍值是>=5 - <=9)。如果省略下限值,則被認為是沒有意義的(例如:參考範圍值是<=2.3)。

            Short參考範圍值的下限值,如果相關。
            Control0..1
            This element is affected by the following invariants: obs-3
            TypeQuantity(SimpleQuantity)
            Is Modifierfalse
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            100. Observation.referenceRange.high
            Definition

            參考範圍值的下限值。參考範圍值endpoint的下限值包含在此值中(例如:參考範圍值是>=5 - <=9)。如果省略下限值,則被認為是沒有意義的(例如:參考範圍值是<=2.3)。

            Short參考範圍值的上限值,如果相關。
            Control0..1
            This element is affected by the following invariants: obs-3
            TypeQuantity(SimpleQuantity)
            Is Modifierfalse
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            102. Observation.referenceRange.type
            Definition

            代碼表明適用的目標人群,例如:正常值或治療範圍值。

            Short參考範圍值的限定詞
            Comments

            如果有一個以上的範圍值,此資料項目 建議應該(SHOULD) 填寫。如果這個資料項目不存在,則假定是正常範圍值。

            Control0..1
            This element is affected by the following invariants: ele-1
            BindingThe codes SHOULD be taken from ObservationReferenceRangeMeaningCodes
            (preferred to http://hl7.org/fhir/ValueSet/referencerange-meaning)

            用以表述參考範圍值之含意的代碼;鼓勵使用所綁定值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。

            TypeCodeableConcept(TW CodeableConcept)
            Is Modifierfalse
            Requirements

            需要能夠說出這是什麼樣的參考範圍值:正常的、建議的、治療的等,以便正確解釋。

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            104. Observation.referenceRange.appliesTo
            Definition

            代碼表明此參考範圍值所適用的目標人群,例如:一個參考範圍值可能是一般人群或特定的性別或種族。多個適用對象需以「AND」解釋目標人群。例如:為了表示一個非裔美國人女性的目標人群,將同時使用女性的代碼和非裔美國人的代碼。

            Short參考範圍值是用適用的對象或人口群
            Comments

            如果有一個以上的範圍值,此資料項目 建議應該(SHOULD) 填寫。如果這個資料項目不存在,則假定是正常範圍值。

            Control0..*
            This element is affected by the following invariants: ele-1
            BindingFor example codes, see ObservationReferenceRangeAppliesToCodes
            (example to http://hl7.org/fhir/ValueSet/referencerange-appliesto)

            用以指明參考範圍值適用的對象或人口群之代碼;可參考所綁定代碼表,但此代碼表只是針對這個欄位的一個可能值的示例,不預期也不鼓勵使用者一定要使用此代碼表的代碼代碼表中的代碼。

            TypeCodeableConcept(TW CodeableConcept)
            Is Modifierfalse
            Requirements

            需要能夠指明目標人群以進行適當的解釋。

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            106. Observation.referenceRange.age
            Definition

            此參考範圍值適用的年齡,如果意思是說足月時的週數,這就是指新生兒年齡。

            Short適用的年齡範圍值,如果相關。
            Control0..1
            TypeRange
            Is Modifierfalse
            Summaryfalse
            Requirements

            有些分析隨著年齡的增長變化很大

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            108. Observation.referenceRange.text
            Definition

            檢驗檢查中以文字表述的參考範圍值,可在不適合以定量範圍值呈現某項檢驗檢查時使用。例如:「陰性 」的參照值或 「正常」的清單/列表。

            Short檢驗檢查中以文字表述的參考範圍值
            Control0..1
            Typestring
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            110. Observation.hasMember
            Definition

            這項檢驗檢查是一組檢驗檢查,例如:一個套組(battery)、一個檢驗套組(panel)或一組生命徵象測量,其組成的檢驗檢查為此資料項目的目標resource。

            Short屬於此組檢驗檢查的相關Resource
            Comments

            使用這個資料項目時,一項檢驗檢查通常會有一個值或者一組相關的resources,儘管在某些情況下兩者都可能存在。有關討論如何將Observations組合在一起的方法,請參閱下面的Notes小節。請注意,系統可能針對問卷調查的結果( QuestionnaireResponse)計算成一個最終的分數,並將這個分數表示為一個Observation。

            Control0..*
            TypeReference(TW Core Observation Vital Signs, TW Core QuestionnaireResponse, MolecularSequence)
            Is Modifierfalse
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            112. Observation.derivedFrom
            Definition

            目標resource為一種測量,此檢驗檢查就是從那個測量中得出。例如:陰離子間隙(an anion gap)或胎兒的測量值是從超音波影像計算而得。

            Short檢驗檢查源自哪些相關測量
            Comments

            在這個資料項目中列出可以代表臨床檢檢查和其他測量的所有參照選項,可能是衍生值的來源。最常見參照另一個Observation,關於Observations如何組合在一起的討論,請參閱下面的Notes小節。

            Control0..*
            TypeReference(TW Core DocumentReference, TW Core ImagingStudy, TW Core Media, TW Core QuestionnaireResponse, TW Core Observation Vital Signs, MolecularSequence)
            Is Modifierfalse
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            114. Observation.component
            Definition

            有有些檢驗檢查有多個組成之檢驗檢查,這些組成之檢驗檢查被表達為具有相同屬性的獨立的代碼值對(code value pair)。例子包括血壓測量的收縮壓和舒張壓即為組成之檢驗檢查(component observations),以及遺傳學檢驗檢查的多個組成之檢驗檢查。

            Short組成之(部分)檢驗檢查的檢驗結果
            Comments

            有關如何組合Observations的方法討論,請參閱下面的Notes小節。

            Control0..*
            TypeBackboneElement
            Is Modifierfalse
            Must Supporttrue
            Summarytrue
            Requirements

            組成之檢驗檢查在Obsrvation resource中與主要檢驗檢查共享相同的屬性,並且總是被視為單個檢驗檢查的一部分(它們是不可分離的)。然而,主要檢驗檢查的參考範圍值並不被組成之檢驗檢查所繼承,在適當的時候需給予每項組成之檢驗檢查參考範圍值。

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            vs-3: If there is no a value a data absent reason must be present (value.exists() or dataAbsentReason.exists())
            116. Observation.component.id
            Definition

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

            ShortUnique id for inter-element referencing
            Control0..1
            Typestring
            Is Modifierfalse
            XML FormatIn the XML format, this property is represented as an attribute.
            Summaryfalse
            118. Observation.component.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.

            ShortAdditional 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.

            Control0..*
            TypeExtension
            Is Modifierfalse
            Summaryfalse
            Alternate Namesextensions, user content
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            120. Observation.component.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).

            ShortExtensions 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.

            Control0..*
            TypeExtension
            Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
            Summarytrue
            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 Namesextensions, user content, modifiers
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            122. Observation.component.code
            Definition

            描述所觀察到的情況,有時這被稱為檢驗檢查「代碼」。

            Short組成之檢驗檢查的型別(代碼/型別)
            Comments

            所有的code-value和component.code-component.value都需要考慮到,以正確理解檢驗檢查的意義。

            Control1..1
            This element is affected by the following invariants: ele-1
            BindingUnless not suitable, these codes SHALL be taken from 生命體徵值集
            (extensible to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/vital-signs-tw)

            代碼指明檢驗檢查的名稱;可參考所綁定值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。

            TypeCodeableConcept(TW CodeableConcept)
            Is Modifierfalse
            Must Supporttrue
            Requirements

            知道正在進行的是哪種檢驗檢查是理解檢驗檢查的關鍵

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            124. Observation.component.value[x]
            Definition

            Vital Sign Value recorded with UCUM.

            ShortVital Sign Value recorded with UCUM
            Comments

            Used when observation has a set of component observations. An observation may have both a value (e.g. an Apgar score) and component observations (the observations from which the Apgar score was derived). If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the Notes section below.

            Control0..1
            This element is affected by the following invariants: vs-3
            BindingUnless not suitable, these codes SHALL be taken from VitalSignsUnits
            (extensible to http://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1)

            Common UCUM units for recording Vital Signs.

            TypeChoice of: Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period
            [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Must Supporttrue
            Must Support TypesQuantity
            Summarytrue
            Requirements
            1. SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:7305).
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            126. Observation.component.dataAbsentReason
            Definition

            提供資料項目Observation.component.value[x]中的預期值缺少的原因

            Short為什麼缺少組成之檢驗檢查結果
            Comments

            空值(Null)或例外值可以在FHIR Observations中以兩種方式表示,一種方法是簡單地將它們含括在值集中,並在值中表示例外。例如:血清檢測的測量值可以是「檢測到」、「未檢測到」、「不確定」或「檢測未完成」。

            另一種方法是使用資料項目value呈現實際檢驗檢查值,並使用資料項目dataAbsentReason來明確記錄例外值。例如:當測量沒有完成,可使用dataAbsentReason代碼「error」。請注意,只有在有值的情況下,才可以報告檢驗檢查。例如:只有在>0的情況下才可能報告細胞計數的差值。由於有這些選項,所以需要有使用案例協議(use-case agreements)來解釋一般檢驗檢查的例外值。

            Control0..1
            This element is affected by the following invariants: ele-1
            BindingUnless not suitable, these codes SHALL be taken from DataAbsentReason
            (extensible to http://hl7.org/fhir/ValueSet/data-absent-reason)

            代碼指明為什麼結果(Observation.value[x])缺少;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。

            TypeCodeableConcept(TW CodeableConcept)
            Is Modifierfalse
            Must Supporttrue
            Requirements

            對於許多結果,必須處理測量中的異常值。

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            128. Observation.component.interpretation
            Definition

            對一項檢驗檢查值的分類評估,例如:高、低、正常。

            Short高、低、正常等。
            Comments

            歷史上用於實驗室結果【被稱為 「異常標記(abnormal flag)」】,它的使用延伸到其他與編碼解釋有關的使用情況中。通常報告為一個或多個簡單的緊密碼(compact code,一種可以解譯且具有最小平均字長的唯一資料代碼),這個資料項目經常被放置在報告和流程表的結果值的旁邊,以表示結果的意義或正常狀態。

            Control0..*
            This element is affected by the following invariants: ele-1
            BindingUnless not suitable, these codes SHALL be taken from ObservationInterpretationCodes
            (extensible to http://hl7.org/fhir/ValueSet/observation-interpretation)

            用以指明檢驗檢查的解釋之代碼。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。

            TypeCodeableConcept(TW CodeableConcept)
            Is Modifierfalse
            Requirements

            對於某些結果,特別是數值結果,需有一個解釋以便完全理解結果之意義。

            Alternate NamesAbnormal Flag
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            130. Observation.component.referenceRange
            Definition

            關於如何透過與正常值或建議範圍值的比較來解釋此值

            Short解釋此組成之檢驗驗查的結果值之指引
            Comments

            大多數檢驗檢查只有一個通用的參考範圍值。系統 可能可以(MAY) 選擇限制只提供病人的相關參考範圍值(例如:具體的病人年齡、性別、體重和其他因素),但這可能是不可能的或也不合適。只要提供了一個以上的參考範圍值,就 建議應該(SHOULD) 提供不同年齡的參考範圍值差異。

            Control0..*
            TypeSeettp://hl7.org/fhir/StructureDefinition/Observation#Observation.referenceRange
            Is Modifierfalse
            Summaryfalse
            Requirements

            知道什麼值被認為是「正常的」,可以幫助評估某一特定結果的意義。需要能夠為不同的情境提供多個參考範圍值。

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