臺灣長期照顧實作指引 (Taiwan Long-Term Care FHIR Implementation Guide)
0.1.1 - ci-build

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

Resource Profile: TWLTC Observation Vital Signs

Official URL: http://ltc-ig.fhir.tw/StructureDefinition/LTCObservationVitalSigns Version: 0.1.1
Draft as of 2024-09-16 Computable Name: LTCObservationVitalSigns

長照機構住民的生命徵象資料

Usage:

  • This Resource Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

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

This structure is derived from TWCoreObservationVitalSigns

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..* TWCoreObservationVitalSigns 檢驗檢查,測量及簡單的判定。
... code 1..1 CodeableConceptTW 量測的生命徵象項目
... subject 1..1 Reference(TW Core Patient) 此生命徵象資料的量測對象
... value[x] 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period 生命徵象量測值

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* TWCoreObservationVitalSigns 檢驗檢查,測量及簡單的判定。
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
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
vs-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present.
... implicitRules ?!Σ 0..1 uri 創建此內容所依據的一組規則
... modifierExtension ?! 0..* Extension 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。
... status ?!SΣ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): 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。

.... category:VSCat S 1..1 CodeableConceptTW 檢驗檢查分類
Binding: ObservationCategoryCodes (preferred): 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。


..... coding SΣ 1..* Coding 由專門術語系統(terminology system)定義的代碼
...... system SΣ 1..1 uri 專門術語系統(terminology system)的識別
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code SΣ 1..1 code 系統定義的語法之符號
Fixed Value: vital-signs
... code S 1..1 CodeableConceptTW 量測的生命徵象項目
Binding: VitalSigns (extensible): 應填入所綁定值集中的其中一個代碼。

.... coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼
.... text SΣ 0..1 string 概念的文字表示法
... subject SΣ 1..1 Reference(TW Core Patient) 此生命徵象資料的量測對象
... effective[x] SΣC 1..1 檢驗檢查執行日期或時間區間
vs-1: if Observation.effective[x] is dateTime and has a value then that value shall be precise to the day
.... effectiveDateTime dateTime
... performer SΣ 0..* Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | TW Core PractitionerRole | CareTeam) 誰負責這項檢驗檢查
... value[x] SΣC 0..1 生命徵象量測值
Binding: VitalSignsUnits (extensible): 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。

.... valueQuantity Quantity
... dataAbsentReason S 0..1 CodeableConceptTW 缺少檢驗檢查結果的原因
Binding: DataAbsentReason (extensible): 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。

... component SΣC 0..* BackboneElement 組成之(部分)檢驗檢查的檢驗結果
vs-3: If there is no a value a data absent reason must be present
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code S 1..1 CodeableConceptTW 組成之檢驗檢查的型別(代碼/型別)
Binding: 生命體徵值集 (required): 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。

.... value[x] SΣC 0..1 Vital Sign Value recorded with UCUM
Binding: VitalSignsUnits (extensible): Common UCUM units for recording Vital Signs.

..... valueQuantity Quantity
.... dataAbsentReason S 0..1 CodeableConceptTW 為什麼缺少組成之檢驗檢查結果
Binding: DataAbsentReason (extensible): 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。


doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:VSCatpreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.codeextensibleVitalSigns
http://hl7.org/fhir/ValueSet/observation-vitalsignresult
from the FHIR Standard
Observation.value[x]extensibleVitalSignsUnits
http://hl7.org/fhir/ValueSet/ucum-vitals-common
from the FHIR Standard
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component.coderequiredTWVitalSigns
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/vital-signs-tw
Observation.component.value[x]extensibleVitalSignsUnits
http://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1
from the FHIR Standard
Observation.component.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorObservationIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorObservationIf 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-4errorObservationIf 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-5errorObservationIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceObservationA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
obs-6errorObservationdataAbsentReason SHALL only be present if Observation.value[x] is not present
: dataAbsentReason.empty() or value.empty()
obs-7errorObservationIf 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-1errorObservation.effective[x]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
vs-2errorObservationIf 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())
vs-3errorObservation.componentIf there is no a value a data absent reason must be present
: value.exists() or dataAbsentReason.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* TWCoreObservationVitalSigns 檢驗檢查,測量及簡單的判定。
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
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
vs-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present.
... id Σ 0..1 id 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。
... meta Σ 0..1 Meta 此Observation Resource的metadata
... implicitRules ?!Σ 0..1 uri 創建此內容所依據的一組規則
... language 0..1 code 用以表述Observation Resource內容的語言。
Binding: CommonLanguages (preferred): 人類語言;鼓勵使用CommonLanguages代碼表中的代碼,但不強制一定要使用此代碼表,你也可使用其他代碼表的代碼或單純以文字表示。

Additional BindingsPurpose
AllLanguages Max Binding

Example Value: zh-TW
... text 0..1 Narrative Observation Resource之內容摘要以供人閱讀
... contained 0..* Resource 內嵌的(contained)、行內的Resources
... extension 0..* Extension 擴充的資料項目
... modifierExtension ?! 0..* Extension 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。
... identifier Σ 0..* Identifier 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。
... basedOn Σ 0..* Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | TW Core MedicationRequest | NutritionOrder | ServiceRequest) 依據的照護計畫/提議/醫令
... partOf Σ 0..* Reference(MedicationAdministration | TW Core MedicationDispense | TW Core MedicationStatement | TW Core Procedure | Immunization | TW Core ImagingStudy) 此檢驗檢查是哪個參照事件的一部分
... status ?!SΣ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): 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。

... Slices for category S 1..* CodeableConceptTW 概念(concept)-參照一個專門術語或只是純文字。
Slice: Unordered, Open by value:coding.code, value:coding.system
Binding: ObservationCategoryCodes (preferred): 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。


.... category:VSCat S 1..1 CodeableConceptTW 檢驗檢查分類
Binding: ObservationCategoryCodes (preferred): 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。


..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣ 1..* Coding 由專門術語系統(terminology system)定義的代碼
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri 專門術語系統(terminology system)的識別
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version Σ 0..1 string 系統的版本—如果相關的話
...... code SΣ 1..1 code 系統定義的語法之符號
Fixed Value: vital-signs
...... display Σ 0..1 string 由系統定義的表示法
...... userSelected Σ 0..1 boolean 此編碼是否由使用者直接選擇?
..... text Σ 0..1 string 概念的文字表示法
... code S 1..1 CodeableConceptTW 量測的生命徵象項目
Binding: VitalSigns (extensible): 應填入所綁定值集中的其中一個代碼。

.... id 0..1 string 唯一可識別ID,以供資料項目間相互參照。
.... extension 0..* Extension 擴充的資料項目
Slice: Unordered, Open by value:url
.... coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼
.... text SΣ 0..1 string 概念的文字表示法
... subject SΣ 1..1 Reference(TW Core Patient) 此生命徵象資料的量測對象
... focus Σ 0..* Reference(Resource) 當檢驗檢查並非有關於與病人本身,檢驗檢查是關於什麼。
... encounter Σ 0..1 Reference(TW Core Encounter) 檢驗檢查是哪一次就醫時執行的
... effective[x] SΣC 1..1 檢驗檢查執行日期或時間區間
vs-1: if Observation.effective[x] is dateTime and has a value then that value shall be precise to the day
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued Σ 0..1 instant 此版本檢驗檢查完成的日期或時間
... performer SΣ 0..* Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | TW Core PractitionerRole | CareTeam) 誰負責這項檢驗檢查
... value[x] SΣC 0..1 生命徵象量測值
Binding: VitalSignsUnits (extensible): 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。

.... valueQuantity Quantity S
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
... dataAbsentReason S 0..1 CodeableConceptTW 缺少檢驗檢查結果的原因
Binding: DataAbsentReason (extensible): 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。

... interpretation 0..* CodeableConceptTW 高、低、正常等
Binding: ObservationInterpretationCodes (extensible): 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。


... note 0..* Annotation 關於此檢驗檢查之解說
... bodySite 0..1 CodeableConceptTW 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。
Binding: SNOMEDCTBodyStructures (extensible): 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。

... method 0..1 CodeableConceptTW 此檢驗檢查使用何種方法完成
Binding: ObservationMethods (extensible): 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。

... specimen 0..1 Reference(TW Core Specimen) 此檢驗檢查的檢體
... device 0..1 Reference(Device | DeviceMetric) (測量)設備
... referenceRange C 0..* BackboneElement 解釋結果值的指引。 obs-3:必須至少有低、高或文字表述。
obs-3: Must have at least a low or a high or text
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... low C 0..1 SimpleQuantity 參考範圍值的下限值,如果相關。
.... high C 0..1 SimpleQuantity 參考範圍值的上限值,如果相關。
.... type 0..1 CodeableConceptTW 參考範圍值的限定詞
Binding: ObservationReferenceRangeMeaningCodes (preferred): 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。

.... appliesTo 0..* CodeableConceptTW 參考範圍值是用適用的對象或人口群
Binding: ObservationReferenceRangeAppliesToCodes (example): 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。


.... age 0..1 Range 適用的年齡範圍值,如果相關。
.... text 0..1 string 檢驗檢查中以文字表述的參考範圍值
... hasMember Σ 0..* Reference(TW Core Observation Vital Signs | QuestionnaireResponse | MolecularSequence) 屬於此組檢驗檢查的相關Resource
... derivedFrom Σ 0..* Reference(TW Core DocumentReference | TW Core ImagingStudy | TW Core Media | QuestionnaireResponse | TW Core Observation Vital Signs | MolecularSequence) 檢驗檢查源自哪些相關測量
... component SΣC 0..* BackboneElement 組成之(部分)檢驗檢查的檢驗結果
vs-3: If there is no a value a data absent reason must be present
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code S 1..1 CodeableConceptTW 組成之檢驗檢查的型別(代碼/型別)
Binding: 生命體徵值集 (required): 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。

.... value[x] SΣC 0..1 Vital Sign Value recorded with UCUM
Binding: VitalSignsUnits (extensible): Common UCUM units for recording Vital Signs.

..... valueQuantity Quantity S
..... valueCodeableConcept CodeableConcept
..... valueString string
..... valueBoolean boolean
..... valueInteger integer
..... valueRange Range
..... valueRatio Ratio
..... valueSampledData SampledData
..... valueTime time
..... valueDateTime dateTime
..... valuePeriod Period
.... dataAbsentReason S 0..1 CodeableConceptTW 為什麼缺少組成之檢驗檢查結果
Binding: DataAbsentReason (extensible): 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。

.... interpretation 0..* CodeableConceptTW 高、低、正常等。
Binding: ObservationInterpretationCodes (extensible): 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。


.... referenceRange 0..* See referenceRange (Observation) 解釋此組成之檢驗驗查的結果值之指引

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:VSCatpreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.codeextensibleVitalSigns
http://hl7.org/fhir/ValueSet/observation-vitalsignresult
from the FHIR Standard
Observation.value[x]extensibleVitalSignsUnits
http://hl7.org/fhir/ValueSet/ucum-vitals-common
from the FHIR Standard
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Observation.methodextensibleObservationMethods
http://hl7.org/fhir/ValueSet/observation-methods
from the FHIR Standard
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
http://hl7.org/fhir/ValueSet/referencerange-meaning
from the FHIR Standard
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
http://hl7.org/fhir/ValueSet/referencerange-appliesto
from the FHIR Standard
Observation.component.coderequiredTWVitalSigns
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/vital-signs-tw
Observation.component.value[x]extensibleVitalSignsUnits
http://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1
from the FHIR Standard
Observation.component.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorObservationIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorObservationIf 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-4errorObservationIf 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-5errorObservationIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceObservationA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
obs-3errorObservation.referenceRangeMust have at least a low or a high or text
: low.exists() or high.exists() or text.exists()
obs-6errorObservationdataAbsentReason SHALL only be present if Observation.value[x] is not present
: dataAbsentReason.empty() or value.empty()
obs-7errorObservationIf 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-1errorObservation.effective[x]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
vs-2errorObservationIf 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())
vs-3errorObservation.componentIf there is no a value a data absent reason must be present
: value.exists() or dataAbsentReason.exists()

This structure is derived from TWCoreObservationVitalSigns

Summary

Differential View

This structure is derived from TWCoreObservationVitalSigns

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..* TWCoreObservationVitalSigns 檢驗檢查,測量及簡單的判定。
... code 1..1 CodeableConceptTW 量測的生命徵象項目
... subject 1..1 Reference(TW Core Patient) 此生命徵象資料的量測對象
... value[x] 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period 生命徵象量測值

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* TWCoreObservationVitalSigns 檢驗檢查,測量及簡單的判定。
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
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
vs-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present.
... implicitRules ?!Σ 0..1 uri 創建此內容所依據的一組規則
... modifierExtension ?! 0..* Extension 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。
... status ?!SΣ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): 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。

.... category:VSCat S 1..1 CodeableConceptTW 檢驗檢查分類
Binding: ObservationCategoryCodes (preferred): 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。


..... coding SΣ 1..* Coding 由專門術語系統(terminology system)定義的代碼
...... system SΣ 1..1 uri 專門術語系統(terminology system)的識別
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code SΣ 1..1 code 系統定義的語法之符號
Fixed Value: vital-signs
... code S 1..1 CodeableConceptTW 量測的生命徵象項目
Binding: VitalSigns (extensible): 應填入所綁定值集中的其中一個代碼。

.... coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼
.... text SΣ 0..1 string 概念的文字表示法
... subject SΣ 1..1 Reference(TW Core Patient) 此生命徵象資料的量測對象
... effective[x] SΣC 1..1 檢驗檢查執行日期或時間區間
vs-1: if Observation.effective[x] is dateTime and has a value then that value shall be precise to the day
.... effectiveDateTime dateTime
... performer SΣ 0..* Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | TW Core PractitionerRole | CareTeam) 誰負責這項檢驗檢查
... value[x] SΣC 0..1 生命徵象量測值
Binding: VitalSignsUnits (extensible): 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。

.... valueQuantity Quantity
... dataAbsentReason S 0..1 CodeableConceptTW 缺少檢驗檢查結果的原因
Binding: DataAbsentReason (extensible): 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。

... component SΣC 0..* BackboneElement 組成之(部分)檢驗檢查的檢驗結果
vs-3: If there is no a value a data absent reason must be present
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code S 1..1 CodeableConceptTW 組成之檢驗檢查的型別(代碼/型別)
Binding: 生命體徵值集 (required): 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。

.... value[x] SΣC 0..1 Vital Sign Value recorded with UCUM
Binding: VitalSignsUnits (extensible): Common UCUM units for recording Vital Signs.

..... valueQuantity Quantity
.... dataAbsentReason S 0..1 CodeableConceptTW 為什麼缺少組成之檢驗檢查結果
Binding: DataAbsentReason (extensible): 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。


doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:VSCatpreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.codeextensibleVitalSigns
http://hl7.org/fhir/ValueSet/observation-vitalsignresult
from the FHIR Standard
Observation.value[x]extensibleVitalSignsUnits
http://hl7.org/fhir/ValueSet/ucum-vitals-common
from the FHIR Standard
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component.coderequiredTWVitalSigns
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/vital-signs-tw
Observation.component.value[x]extensibleVitalSignsUnits
http://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1
from the FHIR Standard
Observation.component.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorObservationIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorObservationIf 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-4errorObservationIf 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-5errorObservationIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceObservationA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
obs-6errorObservationdataAbsentReason SHALL only be present if Observation.value[x] is not present
: dataAbsentReason.empty() or value.empty()
obs-7errorObservationIf 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-1errorObservation.effective[x]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
vs-2errorObservationIf 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())
vs-3errorObservation.componentIf there is no a value a data absent reason must be present
: value.exists() or dataAbsentReason.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* TWCoreObservationVitalSigns 檢驗檢查,測量及簡單的判定。
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
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
vs-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present.
... id Σ 0..1 id 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。
... meta Σ 0..1 Meta 此Observation Resource的metadata
... implicitRules ?!Σ 0..1 uri 創建此內容所依據的一組規則
... language 0..1 code 用以表述Observation Resource內容的語言。
Binding: CommonLanguages (preferred): 人類語言;鼓勵使用CommonLanguages代碼表中的代碼,但不強制一定要使用此代碼表,你也可使用其他代碼表的代碼或單純以文字表示。

Additional BindingsPurpose
AllLanguages Max Binding

Example Value: zh-TW
... text 0..1 Narrative Observation Resource之內容摘要以供人閱讀
... contained 0..* Resource 內嵌的(contained)、行內的Resources
... extension 0..* Extension 擴充的資料項目
... modifierExtension ?! 0..* Extension 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。
... identifier Σ 0..* Identifier 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。
... basedOn Σ 0..* Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | TW Core MedicationRequest | NutritionOrder | ServiceRequest) 依據的照護計畫/提議/醫令
... partOf Σ 0..* Reference(MedicationAdministration | TW Core MedicationDispense | TW Core MedicationStatement | TW Core Procedure | Immunization | TW Core ImagingStudy) 此檢驗檢查是哪個參照事件的一部分
... status ?!SΣ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): 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。

... Slices for category S 1..* CodeableConceptTW 概念(concept)-參照一個專門術語或只是純文字。
Slice: Unordered, Open by value:coding.code, value:coding.system
Binding: ObservationCategoryCodes (preferred): 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。


.... category:VSCat S 1..1 CodeableConceptTW 檢驗檢查分類
Binding: ObservationCategoryCodes (preferred): 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。


..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣ 1..* Coding 由專門術語系統(terminology system)定義的代碼
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri 專門術語系統(terminology system)的識別
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version Σ 0..1 string 系統的版本—如果相關的話
...... code SΣ 1..1 code 系統定義的語法之符號
Fixed Value: vital-signs
...... display Σ 0..1 string 由系統定義的表示法
...... userSelected Σ 0..1 boolean 此編碼是否由使用者直接選擇?
..... text Σ 0..1 string 概念的文字表示法
... code S 1..1 CodeableConceptTW 量測的生命徵象項目
Binding: VitalSigns (extensible): 應填入所綁定值集中的其中一個代碼。

.... id 0..1 string 唯一可識別ID,以供資料項目間相互參照。
.... extension 0..* Extension 擴充的資料項目
Slice: Unordered, Open by value:url
.... coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼
.... text SΣ 0..1 string 概念的文字表示法
... subject SΣ 1..1 Reference(TW Core Patient) 此生命徵象資料的量測對象
... focus Σ 0..* Reference(Resource) 當檢驗檢查並非有關於與病人本身,檢驗檢查是關於什麼。
... encounter Σ 0..1 Reference(TW Core Encounter) 檢驗檢查是哪一次就醫時執行的
... effective[x] SΣC 1..1 檢驗檢查執行日期或時間區間
vs-1: if Observation.effective[x] is dateTime and has a value then that value shall be precise to the day
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued Σ 0..1 instant 此版本檢驗檢查完成的日期或時間
... performer SΣ 0..* Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | TW Core PractitionerRole | CareTeam) 誰負責這項檢驗檢查
... value[x] SΣC 0..1 生命徵象量測值
Binding: VitalSignsUnits (extensible): 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。

.... valueQuantity Quantity S
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
... dataAbsentReason S 0..1 CodeableConceptTW 缺少檢驗檢查結果的原因
Binding: DataAbsentReason (extensible): 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。

... interpretation 0..* CodeableConceptTW 高、低、正常等
Binding: ObservationInterpretationCodes (extensible): 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。


... note 0..* Annotation 關於此檢驗檢查之解說
... bodySite 0..1 CodeableConceptTW 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。
Binding: SNOMEDCTBodyStructures (extensible): 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。

... method 0..1 CodeableConceptTW 此檢驗檢查使用何種方法完成
Binding: ObservationMethods (extensible): 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。

... specimen 0..1 Reference(TW Core Specimen) 此檢驗檢查的檢體
... device 0..1 Reference(Device | DeviceMetric) (測量)設備
... referenceRange C 0..* BackboneElement 解釋結果值的指引。 obs-3:必須至少有低、高或文字表述。
obs-3: Must have at least a low or a high or text
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... low C 0..1 SimpleQuantity 參考範圍值的下限值,如果相關。
.... high C 0..1 SimpleQuantity 參考範圍值的上限值,如果相關。
.... type 0..1 CodeableConceptTW 參考範圍值的限定詞
Binding: ObservationReferenceRangeMeaningCodes (preferred): 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。

.... appliesTo 0..* CodeableConceptTW 參考範圍值是用適用的對象或人口群
Binding: ObservationReferenceRangeAppliesToCodes (example): 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。


.... age 0..1 Range 適用的年齡範圍值,如果相關。
.... text 0..1 string 檢驗檢查中以文字表述的參考範圍值
... hasMember Σ 0..* Reference(TW Core Observation Vital Signs | QuestionnaireResponse | MolecularSequence) 屬於此組檢驗檢查的相關Resource
... derivedFrom Σ 0..* Reference(TW Core DocumentReference | TW Core ImagingStudy | TW Core Media | QuestionnaireResponse | TW Core Observation Vital Signs | MolecularSequence) 檢驗檢查源自哪些相關測量
... component SΣC 0..* BackboneElement 組成之(部分)檢驗檢查的檢驗結果
vs-3: If there is no a value a data absent reason must be present
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code S 1..1 CodeableConceptTW 組成之檢驗檢查的型別(代碼/型別)
Binding: 生命體徵值集 (required): 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。

.... value[x] SΣC 0..1 Vital Sign Value recorded with UCUM
Binding: VitalSignsUnits (extensible): Common UCUM units for recording Vital Signs.

..... valueQuantity Quantity S
..... valueCodeableConcept CodeableConcept
..... valueString string
..... valueBoolean boolean
..... valueInteger integer
..... valueRange Range
..... valueRatio Ratio
..... valueSampledData SampledData
..... valueTime time
..... valueDateTime dateTime
..... valuePeriod Period
.... dataAbsentReason S 0..1 CodeableConceptTW 為什麼缺少組成之檢驗檢查結果
Binding: DataAbsentReason (extensible): 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。

.... interpretation 0..* CodeableConceptTW 高、低、正常等。
Binding: ObservationInterpretationCodes (extensible): 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。


.... referenceRange 0..* See referenceRange (Observation) 解釋此組成之檢驗驗查的結果值之指引

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:VSCatpreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.codeextensibleVitalSigns
http://hl7.org/fhir/ValueSet/observation-vitalsignresult
from the FHIR Standard
Observation.value[x]extensibleVitalSignsUnits
http://hl7.org/fhir/ValueSet/ucum-vitals-common
from the FHIR Standard
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Observation.methodextensibleObservationMethods
http://hl7.org/fhir/ValueSet/observation-methods
from the FHIR Standard
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
http://hl7.org/fhir/ValueSet/referencerange-meaning
from the FHIR Standard
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
http://hl7.org/fhir/ValueSet/referencerange-appliesto
from the FHIR Standard
Observation.component.coderequiredTWVitalSigns
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/vital-signs-tw
Observation.component.value[x]extensibleVitalSignsUnits
http://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1
from the FHIR Standard
Observation.component.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorObservationIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorObservationIf 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-4errorObservationIf 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-5errorObservationIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceObservationA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
obs-3errorObservation.referenceRangeMust have at least a low or a high or text
: low.exists() or high.exists() or text.exists()
obs-6errorObservationdataAbsentReason SHALL only be present if Observation.value[x] is not present
: dataAbsentReason.empty() or value.empty()
obs-7errorObservationIf 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-1errorObservation.effective[x]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
vs-2errorObservationIf 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())
vs-3errorObservation.componentIf there is no a value a data absent reason must be present
: value.exists() or dataAbsentReason.exists()

This structure is derived from TWCoreObservationVitalSigns

Summary

 

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