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
Official URL: http://ltc-ig.fhir.tw/StructureDefinition/PASportConditionMedicalHistory | Version: 0.2.0 | |||
Active as of 2024-10-23 | Computable Name: PASportConditionMedicalHistory |
長照機構住民運動處方的病史資料,本 Profile 繼承自身體活動量測 (Physical Activity Measure) 的 Sport Data Condition Profile。
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from LTCCondition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | 0..* | LTCCondition | 有關病情、問題或診斷的詳細資訊 | |
category | ||||
coding | 1..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 | |
system | 1..1 | uri | 專門術語系統(terminology system)的識別 Required Pattern: http://loinc.org | |
code | 1..1 | code | 系統定義的語法之符號 Required Pattern: 10164-2 | |
display | 0..1 | string | 由系統定義的表示法 Required Pattern: History of medical condition | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | C | 0..* | LTCCondition | 有關病情、問題或診斷的詳細資訊 con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error |
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
clinicalStatus | S | 1..1 | CodeableConceptTW | active | recurrence | relapse | inactive | remission | resolved ,病情、問題或診斷的臨床狀態。 Binding: ConditionClinicalStatusCodes (required): 應填入所綁定值集中的其中一個代碼。 |
verificationStatus | S | 0..1 | CodeableConceptTW | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error ,支持或拒絕病情、問題或診斷的臨床狀態的驗證狀態。 Binding: ConditionVerificationStatus (required): 應填入所綁定值集中的其中一個代碼。 |
category | S | 1..1 | CodeableConceptTW | problem-list-item | encounter-diagnosis ,指定病情、問題或診斷的類別。 Binding: ConditionCategoryCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 |
coding | S | 1..1 | CodingTW | 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 Required Pattern: http://loinc.org |
code | SΣ | 1..1 | code | 系統定義的語法之符號 Required Pattern: 10164-2 |
display | SΣ | 0..1 | string | 由系統定義的表示法 Required Pattern: History of medical condition |
text | SΣ | 0..1 | string | 概念的文字表示法 |
severity | S | 0..1 | CodeableConceptTW | 病情、問題或診斷的主觀嚴重程度 Binding: Condition/DiagnosisSeverity (extensible): 臨床醫生對病情、問題或診斷嚴重程度的主觀評價;應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 |
code | S | 1..1 | CodeableConceptTW | 病情、問題或診斷的識別 Binding: Condition/Problem/DiagnosisCodes (example): 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 |
Slices for coding | S | 0..* | CodingTW | 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 Slice: Unordered, Open by pattern:$this |
coding:icd10-cm-2023 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (required) |
coding:icd10-cm-2021 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2021年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。 |
coding:icd10-cm-2014 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。 |
coding:icd9-cm-2001 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required) |
coding:absentOrUnknownProblem | S | 0..1 | CodingTW | 不存在的問題或未知問題的代碼 Binding: Absent or Unknown Problems - IPS (required): 應填入所綁定值集中的其中一個代碼。 |
coding:sct | S | 0..1 | CodingTW | 此為SNOMED CT診斷代碼,若機構已有購買相關授權,亦可使用。 Binding: SNOMED CT診斷代碼值集 (required): 應填入所綁定值集中的其中一個代碼。 |
text | SΣ | 0..1 | string | 概念的文字表示法 |
bodySite | S | 0..* | CodeableConceptTW | 如果相關請填寫解剖位置 Binding: SNOMEDCTBodyStructures (extensible): 描述解剖位置的代碼。可包括側面;應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 |
subject | SΣ | 1..1 | Reference(長期照顧-住民基本資料) | 誰有此病情、問題或診斷? |
reference | SΣC | 1..1 | string | 擁有此病情、問題或診斷的住民。[應輸入 Patient Resource ID] |
onset[x] | SΣ | 0..1 | 估計的或實際的日期、日期—時間或年齡。 | |
onsetDateTime | dateTime | |||
abatement[x] | SC | 0..1 | 何時解決/緩解 | |
abatementDateTime | dateTime | |||
recorder | SΣ | 0..1 | Reference(長期照顧-照顧服務提供者 | 長期照顧-服務人員角色 | 長期照顧-住民基本資料 | 長期照顧-關係人) | 誰記錄此病情、問題或診斷 |
reference | SΣC | 1..1 | string | 記錄此病情、問題或診斷的人員。[應輸入 Practitioner/PractitionerRole/Patient/RelatedPerson Resource ID] |
asserter | SΣ | 0..1 | Reference(長期照顧-照顧服務提供者 | 長期照顧-服務人員角色 | 長期照顧-住民基本資料 | 長期照顧-關係人) | 聲稱有此病情、問題或診斷的人 |
reference | SΣC | 1..1 | string | 聲稱有此病情、問題或診斷的人員。[應輸入 Practitioner/PractitionerRole/Patient/RelatedPerson Resource ID] |
note | S | 0..* | Annotation | 關於此Condition的附加資訊 |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | |
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | |
Condition.category | extensible | ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard | |
Condition.severity | extensible | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | |
Condition.code | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | |
Condition.code.coding:icd10-cm-2023 | required | TW2023ICD10CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2023-tw | |
Condition.code.coding:icd10-cm-2021 | required | TW2021ICD10CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2021-tw | |
Condition.code.coding:icd10-cm-2014 | required | TW2014ICD10CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2014-tw | |
Condition.code.coding:icd9-cm-2001 | required | TW2001ICD9CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw | |
Condition.code.coding:absentOrUnknownProblem | required | AbsentOrUnknownProblemsUvIpshttp://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips | |
Condition.code.coding:sct | required | TWConditionCodeSCThttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw | |
Condition.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | LTCCondition | 有關病情、問題或診斷的詳細資訊 con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error | ||||
id | Σ | 0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的Condition紀錄,通常又稱為邏輯性ID。 | ||||
meta | Σ | 0..1 | Meta | 此Condition Resource的metadata | ||||
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 | ||||
language | 0..1 | code | 用以表述Condition Resource內容的語言。 Binding: CommonLanguages (preferred): 人類語言;鼓勵使用CommonLanguages代碼表中的代碼,但不強制一定要使用此代碼表,你也可使用其他代碼表的代碼或單純以文字表示。
Example Value: zh-TW | |||||
text | 0..1 | Narrative | Condition Resource之內容摘要以供人閱讀 | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | 此病情、問題或診斷的外部識別碼 | ||||
clinicalStatus | S | 1..1 | CodeableConceptTW | active | recurrence | relapse | inactive | remission | resolved ,病情、問題或診斷的臨床狀態。 Binding: ConditionClinicalStatusCodes (required): 應填入所綁定值集中的其中一個代碼。 | ||||
verificationStatus | S | 0..1 | CodeableConceptTW | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error ,支持或拒絕病情、問題或診斷的臨床狀態的驗證狀態。 Binding: ConditionVerificationStatus (required): 應填入所綁定值集中的其中一個代碼。 | ||||
category | S | 1..1 | CodeableConceptTW | problem-list-item | encounter-diagnosis ,指定病情、問題或診斷的類別。 Binding: ConditionCategoryCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
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 | 1..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 | ||||
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 | |||||
system | SΣ | 1..1 | uri | 專門術語系統(terminology system)的識別 Required Pattern: http://loinc.org | ||||
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 Required Pattern: 10164-2 | ||||
display | SΣ | 0..1 | string | 由系統定義的表示法 Required Pattern: History of medical condition | ||||
userSelected | Σ | 0..1 | boolean | 此編碼是否由使用者直接選擇? | ||||
text | SΣ | 0..1 | string | 概念的文字表示法 | ||||
severity | S | 0..1 | CodeableConceptTW | 病情、問題或診斷的主觀嚴重程度 Binding: Condition/DiagnosisSeverity (extensible): 臨床醫生對病情、問題或診斷嚴重程度的主觀評價;應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
code | S | 1..1 | CodeableConceptTW | 病情、問題或診斷的識別 Binding: Condition/Problem/DiagnosisCodes (example): 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 | ||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 Slice: Unordered, Open by value:url | |||||
Slices for coding | S | 0..* | CodingTW | 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 Slice: Unordered, Open by pattern:$this | ||||
coding:icd10-cm-2023 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (required) | ||||
coding:icd10-cm-2021 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2021年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:icd10-cm-2014 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:icd9-cm-2001 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required) | ||||
coding:absentOrUnknownProblem | S | 0..1 | CodingTW | 不存在的問題或未知問題的代碼 Binding: Absent or Unknown Problems - IPS (required): 應填入所綁定值集中的其中一個代碼。 | ||||
coding:sct | S | 0..1 | CodingTW | 此為SNOMED CT診斷代碼,若機構已有購買相關授權,亦可使用。 Binding: SNOMED CT診斷代碼值集 (required): 應填入所綁定值集中的其中一個代碼。 | ||||
text | SΣ | 0..1 | string | 概念的文字表示法 | ||||
bodySite | S | 0..* | CodeableConceptTW | 如果相關請填寫解剖位置 Binding: SNOMEDCTBodyStructures (extensible): 描述解剖位置的代碼。可包括側面;應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
subject | SΣ | 1..1 | Reference(長期照顧-住民基本資料) | 誰有此病情、問題或診斷? | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | SΣC | 1..1 | string | 擁有此病情、問題或診斷的住民。[應輸入 Patient Resource ID] | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
display | Σ | 0..1 | string | Text alternative for the resource | ||||
encounter | Σ | 0..1 | Reference(TW Core Encounter) | 作為病情、問題或診斷紀錄的一部分的就醫(Encounter)紀錄 | ||||
onset[x] | SΣ | 0..1 | 估計的或實際的日期、日期—時間或年齡。 | |||||
onsetDateTime | dateTime S | |||||||
onsetAge | Age | |||||||
onsetPeriod | Period | |||||||
onsetRange | Range | |||||||
onsetString | string | |||||||
abatement[x] | SC | 0..1 | 何時解決/緩解 | |||||
abatementDateTime | dateTime S | |||||||
abatementAge | Age | |||||||
abatementPeriod | Period | |||||||
abatementRange | Range | |||||||
abatementString | string | |||||||
recordedDate | Σ | 0..1 | dateTime | 記錄的日期 | ||||
recorder | SΣ | 0..1 | Reference(長期照顧-照顧服務提供者 | 長期照顧-服務人員角色 | 長期照顧-住民基本資料 | 長期照顧-關係人) | 誰記錄此病情、問題或診斷 | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | SΣC | 1..1 | string | 記錄此病情、問題或診斷的人員。[應輸入 Practitioner/PractitionerRole/Patient/RelatedPerson Resource ID] | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
display | Σ | 0..1 | string | Text alternative for the resource | ||||
asserter | SΣ | 0..1 | Reference(長期照顧-照顧服務提供者 | 長期照顧-服務人員角色 | 長期照顧-住民基本資料 | 長期照顧-關係人) | 聲稱有此病情、問題或診斷的人 | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | SΣC | 1..1 | string | 聲稱有此病情、問題或診斷的人員。[應輸入 Practitioner/PractitionerRole/Patient/RelatedPerson Resource ID] | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
display | Σ | 0..1 | string | Text alternative for the resource | ||||
stage | C | 0..* | BackboneElement | 分期(stage)/分級(grade),通常是正式的評估。 con-1: Stage SHALL have summary or assessment | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
summary | 0..1 | CodeableConceptTW | 簡單的摘要(特定疾病)。 Binding: ConditionStage (extensible): 描述病情、問題或診斷分期的代碼(例如:癌症分期)。應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | |||||
assessment | C | 0..* | Reference(ClinicalImpression | TW Core DiagnosticReport | TW Core Observation Laboratory Result | TW Core Observation Vital Signs) | 正式的評估記錄 | ||||
type | 0..1 | CodeableConceptTW | 分期的種類 Binding: ConditionStageType (extensible): 病情、問題或診斷分期種類的代碼(如臨床或病理);應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | |||||
evidence | C | 0..* | BackboneElement | 支持的證據 con-2: evidence SHALL have code or details | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | 0..* | CodeableConceptTW | 表現/症狀 Binding: ManifestationAndSymptomCodes (extensible): 病情、問題或診斷的表現或症狀之代碼;應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | |||||
detail | ΣC | 0..* | Reference(Resource) | 在其他地方找到的支持資訊 | ||||
note | S | 0..* | Annotation | 關於此Condition的附加資訊 | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Condition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | ||||
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | ||||
Condition.category | extensible | ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard | ||||
Condition.severity | extensible | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | ||||
Condition.code | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Condition.code.coding:icd10-cm-2023 | required | TW2023ICD10CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2023-tw | ||||
Condition.code.coding:icd10-cm-2021 | required | TW2021ICD10CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2021-tw | ||||
Condition.code.coding:icd10-cm-2014 | required | TW2014ICD10CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2014-tw | ||||
Condition.code.coding:icd9-cm-2001 | required | TW2001ICD9CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw | ||||
Condition.code.coding:absentOrUnknownProblem | required | AbsentOrUnknownProblemsUvIpshttp://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips | ||||
Condition.code.coding:sct | required | TWConditionCodeSCThttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw | ||||
Condition.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Condition.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Condition.recorder.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Condition.asserter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Condition.stage.summary | extensible | ConditionStagehttp://hl7.org/fhir/ValueSet/condition-stage from the FHIR Standard | ||||
Condition.stage.type | extensible | ConditionStageTypehttp://hl7.org/fhir/ValueSet/condition-stage-type from the FHIR Standard | ||||
Condition.evidence.code | extensible | ManifestationAndSymptomCodeshttp://hl7.org/fhir/ValueSet/manifestation-or-symptom from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
con-1 | error | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.exists() | |
con-2 | error | Condition.evidence | evidence SHALL have code or details : code.exists() or detail.exists() | |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from LTCCondition
Differential View
This structure is derived from LTCCondition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | 0..* | LTCCondition | 有關病情、問題或診斷的詳細資訊 | |
category | ||||
coding | 1..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 | |
system | 1..1 | uri | 專門術語系統(terminology system)的識別 Required Pattern: http://loinc.org | |
code | 1..1 | code | 系統定義的語法之符號 Required Pattern: 10164-2 | |
display | 0..1 | string | 由系統定義的表示法 Required Pattern: History of medical condition | |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | C | 0..* | LTCCondition | 有關病情、問題或診斷的詳細資訊 con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error |
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
clinicalStatus | S | 1..1 | CodeableConceptTW | active | recurrence | relapse | inactive | remission | resolved ,病情、問題或診斷的臨床狀態。 Binding: ConditionClinicalStatusCodes (required): 應填入所綁定值集中的其中一個代碼。 |
verificationStatus | S | 0..1 | CodeableConceptTW | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error ,支持或拒絕病情、問題或診斷的臨床狀態的驗證狀態。 Binding: ConditionVerificationStatus (required): 應填入所綁定值集中的其中一個代碼。 |
category | S | 1..1 | CodeableConceptTW | problem-list-item | encounter-diagnosis ,指定病情、問題或診斷的類別。 Binding: ConditionCategoryCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 |
coding | S | 1..1 | CodingTW | 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 Required Pattern: http://loinc.org |
code | SΣ | 1..1 | code | 系統定義的語法之符號 Required Pattern: 10164-2 |
display | SΣ | 0..1 | string | 由系統定義的表示法 Required Pattern: History of medical condition |
text | SΣ | 0..1 | string | 概念的文字表示法 |
severity | S | 0..1 | CodeableConceptTW | 病情、問題或診斷的主觀嚴重程度 Binding: Condition/DiagnosisSeverity (extensible): 臨床醫生對病情、問題或診斷嚴重程度的主觀評價;應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 |
code | S | 1..1 | CodeableConceptTW | 病情、問題或診斷的識別 Binding: Condition/Problem/DiagnosisCodes (example): 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 |
Slices for coding | S | 0..* | CodingTW | 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 Slice: Unordered, Open by pattern:$this |
coding:icd10-cm-2023 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (required) |
coding:icd10-cm-2021 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2021年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。 |
coding:icd10-cm-2014 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。 |
coding:icd9-cm-2001 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required) |
coding:absentOrUnknownProblem | S | 0..1 | CodingTW | 不存在的問題或未知問題的代碼 Binding: Absent or Unknown Problems - IPS (required): 應填入所綁定值集中的其中一個代碼。 |
coding:sct | S | 0..1 | CodingTW | 此為SNOMED CT診斷代碼,若機構已有購買相關授權,亦可使用。 Binding: SNOMED CT診斷代碼值集 (required): 應填入所綁定值集中的其中一個代碼。 |
text | SΣ | 0..1 | string | 概念的文字表示法 |
bodySite | S | 0..* | CodeableConceptTW | 如果相關請填寫解剖位置 Binding: SNOMEDCTBodyStructures (extensible): 描述解剖位置的代碼。可包括側面;應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 |
subject | SΣ | 1..1 | Reference(長期照顧-住民基本資料) | 誰有此病情、問題或診斷? |
reference | SΣC | 1..1 | string | 擁有此病情、問題或診斷的住民。[應輸入 Patient Resource ID] |
onset[x] | SΣ | 0..1 | 估計的或實際的日期、日期—時間或年齡。 | |
onsetDateTime | dateTime | |||
abatement[x] | SC | 0..1 | 何時解決/緩解 | |
abatementDateTime | dateTime | |||
recorder | SΣ | 0..1 | Reference(長期照顧-照顧服務提供者 | 長期照顧-服務人員角色 | 長期照顧-住民基本資料 | 長期照顧-關係人) | 誰記錄此病情、問題或診斷 |
reference | SΣC | 1..1 | string | 記錄此病情、問題或診斷的人員。[應輸入 Practitioner/PractitionerRole/Patient/RelatedPerson Resource ID] |
asserter | SΣ | 0..1 | Reference(長期照顧-照顧服務提供者 | 長期照顧-服務人員角色 | 長期照顧-住民基本資料 | 長期照顧-關係人) | 聲稱有此病情、問題或診斷的人 |
reference | SΣC | 1..1 | string | 聲稱有此病情、問題或診斷的人員。[應輸入 Practitioner/PractitionerRole/Patient/RelatedPerson Resource ID] |
note | S | 0..* | Annotation | 關於此Condition的附加資訊 |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | |
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | |
Condition.category | extensible | ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard | |
Condition.severity | extensible | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | |
Condition.code | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | |
Condition.code.coding:icd10-cm-2023 | required | TW2023ICD10CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2023-tw | |
Condition.code.coding:icd10-cm-2021 | required | TW2021ICD10CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2021-tw | |
Condition.code.coding:icd10-cm-2014 | required | TW2014ICD10CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2014-tw | |
Condition.code.coding:icd9-cm-2001 | required | TW2001ICD9CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw | |
Condition.code.coding:absentOrUnknownProblem | required | AbsentOrUnknownProblemsUvIpshttp://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips | |
Condition.code.coding:sct | required | TWConditionCodeSCThttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw | |
Condition.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | LTCCondition | 有關病情、問題或診斷的詳細資訊 con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error | ||||
id | Σ | 0..1 | id | 不重複的ID用以識別儲存在特定FHIR Server中的Condition紀錄,通常又稱為邏輯性ID。 | ||||
meta | Σ | 0..1 | Meta | 此Condition Resource的metadata | ||||
implicitRules | ?!Σ | 0..1 | uri | 創建此內容所依據的一組規則 | ||||
language | 0..1 | code | 用以表述Condition Resource內容的語言。 Binding: CommonLanguages (preferred): 人類語言;鼓勵使用CommonLanguages代碼表中的代碼,但不強制一定要使用此代碼表,你也可使用其他代碼表的代碼或單純以文字表示。
Example Value: zh-TW | |||||
text | 0..1 | Narrative | Condition Resource之內容摘要以供人閱讀 | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | 此病情、問題或診斷的外部識別碼 | ||||
clinicalStatus | S | 1..1 | CodeableConceptTW | active | recurrence | relapse | inactive | remission | resolved ,病情、問題或診斷的臨床狀態。 Binding: ConditionClinicalStatusCodes (required): 應填入所綁定值集中的其中一個代碼。 | ||||
verificationStatus | S | 0..1 | CodeableConceptTW | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error ,支持或拒絕病情、問題或診斷的臨床狀態的驗證狀態。 Binding: ConditionVerificationStatus (required): 應填入所綁定值集中的其中一個代碼。 | ||||
category | S | 1..1 | CodeableConceptTW | problem-list-item | encounter-diagnosis ,指定病情、問題或診斷的類別。 Binding: ConditionCategoryCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
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 | 1..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 | ||||
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 | |||||
system | SΣ | 1..1 | uri | 專門術語系統(terminology system)的識別 Required Pattern: http://loinc.org | ||||
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 Required Pattern: 10164-2 | ||||
display | SΣ | 0..1 | string | 由系統定義的表示法 Required Pattern: History of medical condition | ||||
userSelected | Σ | 0..1 | boolean | 此編碼是否由使用者直接選擇? | ||||
text | SΣ | 0..1 | string | 概念的文字表示法 | ||||
severity | S | 0..1 | CodeableConceptTW | 病情、問題或診斷的主觀嚴重程度 Binding: Condition/DiagnosisSeverity (extensible): 臨床醫生對病情、問題或診斷嚴重程度的主觀評價;應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
code | S | 1..1 | CodeableConceptTW | 病情、問題或診斷的識別 Binding: Condition/Problem/DiagnosisCodes (example): 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 | ||||
id | 0..1 | string | 唯一可識別ID,以供資料項目間相互參照。 | |||||
extension | 0..* | Extension | 擴充的資料項目 Slice: Unordered, Open by value:url | |||||
Slices for coding | S | 0..* | CodingTW | 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。 Slice: Unordered, Open by pattern:$this | ||||
coding:icd10-cm-2023 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (required) | ||||
coding:icd10-cm-2021 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2021年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:icd10-cm-2014 | S | 0..1 | CodingTW | 此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。 Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。 | ||||
coding:icd9-cm-2001 | S | 0..1 | CodingTW | 由專門術語系統(terminology system)定義的代碼 Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required) | ||||
coding:absentOrUnknownProblem | S | 0..1 | CodingTW | 不存在的問題或未知問題的代碼 Binding: Absent or Unknown Problems - IPS (required): 應填入所綁定值集中的其中一個代碼。 | ||||
coding:sct | S | 0..1 | CodingTW | 此為SNOMED CT診斷代碼,若機構已有購買相關授權,亦可使用。 Binding: SNOMED CT診斷代碼值集 (required): 應填入所綁定值集中的其中一個代碼。 | ||||
text | SΣ | 0..1 | string | 概念的文字表示法 | ||||
bodySite | S | 0..* | CodeableConceptTW | 如果相關請填寫解剖位置 Binding: SNOMEDCTBodyStructures (extensible): 描述解剖位置的代碼。可包括側面;應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | ||||
subject | SΣ | 1..1 | Reference(長期照顧-住民基本資料) | 誰有此病情、問題或診斷? | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | SΣC | 1..1 | string | 擁有此病情、問題或診斷的住民。[應輸入 Patient Resource ID] | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
display | Σ | 0..1 | string | Text alternative for the resource | ||||
encounter | Σ | 0..1 | Reference(TW Core Encounter) | 作為病情、問題或診斷紀錄的一部分的就醫(Encounter)紀錄 | ||||
onset[x] | SΣ | 0..1 | 估計的或實際的日期、日期—時間或年齡。 | |||||
onsetDateTime | dateTime S | |||||||
onsetAge | Age | |||||||
onsetPeriod | Period | |||||||
onsetRange | Range | |||||||
onsetString | string | |||||||
abatement[x] | SC | 0..1 | 何時解決/緩解 | |||||
abatementDateTime | dateTime S | |||||||
abatementAge | Age | |||||||
abatementPeriod | Period | |||||||
abatementRange | Range | |||||||
abatementString | string | |||||||
recordedDate | Σ | 0..1 | dateTime | 記錄的日期 | ||||
recorder | SΣ | 0..1 | Reference(長期照顧-照顧服務提供者 | 長期照顧-服務人員角色 | 長期照顧-住民基本資料 | 長期照顧-關係人) | 誰記錄此病情、問題或診斷 | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | SΣC | 1..1 | string | 記錄此病情、問題或診斷的人員。[應輸入 Practitioner/PractitionerRole/Patient/RelatedPerson Resource ID] | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
display | Σ | 0..1 | string | Text alternative for the resource | ||||
asserter | SΣ | 0..1 | Reference(長期照顧-照顧服務提供者 | 長期照顧-服務人員角色 | 長期照顧-住民基本資料 | 長期照顧-關係人) | 聲稱有此病情、問題或診斷的人 | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | SΣC | 1..1 | string | 聲稱有此病情、問題或診斷的人員。[應輸入 Practitioner/PractitionerRole/Patient/RelatedPerson Resource ID] | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
display | Σ | 0..1 | string | Text alternative for the resource | ||||
stage | C | 0..* | BackboneElement | 分期(stage)/分級(grade),通常是正式的評估。 con-1: Stage SHALL have summary or assessment | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
summary | 0..1 | CodeableConceptTW | 簡單的摘要(特定疾病)。 Binding: ConditionStage (extensible): 描述病情、問題或診斷分期的代碼(例如:癌症分期)。應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | |||||
assessment | C | 0..* | Reference(ClinicalImpression | TW Core DiagnosticReport | TW Core Observation Laboratory Result | TW Core Observation Vital Signs) | 正式的評估記錄 | ||||
type | 0..1 | CodeableConceptTW | 分期的種類 Binding: ConditionStageType (extensible): 病情、問題或診斷分期種類的代碼(如臨床或病理);應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | |||||
evidence | C | 0..* | BackboneElement | 支持的證據 con-2: evidence SHALL have code or details | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | 0..* | CodeableConceptTW | 表現/症狀 Binding: ManifestationAndSymptomCodes (extensible): 病情、問題或診斷的表現或症狀之代碼;應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。 | |||||
detail | ΣC | 0..* | Reference(Resource) | 在其他地方找到的支持資訊 | ||||
note | S | 0..* | Annotation | 關於此Condition的附加資訊 | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Condition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | ||||
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | ||||
Condition.category | extensible | ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard | ||||
Condition.severity | extensible | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | ||||
Condition.code | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Condition.code.coding:icd10-cm-2023 | required | TW2023ICD10CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2023-tw | ||||
Condition.code.coding:icd10-cm-2021 | required | TW2021ICD10CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2021-tw | ||||
Condition.code.coding:icd10-cm-2014 | required | TW2014ICD10CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2014-tw | ||||
Condition.code.coding:icd9-cm-2001 | required | TW2001ICD9CMhttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw | ||||
Condition.code.coding:absentOrUnknownProblem | required | AbsentOrUnknownProblemsUvIpshttp://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips | ||||
Condition.code.coding:sct | required | TWConditionCodeSCThttps://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw | ||||
Condition.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Condition.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Condition.recorder.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Condition.asserter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Condition.stage.summary | extensible | ConditionStagehttp://hl7.org/fhir/ValueSet/condition-stage from the FHIR Standard | ||||
Condition.stage.type | extensible | ConditionStageTypehttp://hl7.org/fhir/ValueSet/condition-stage-type from the FHIR Standard | ||||
Condition.evidence.code | extensible | ManifestationAndSymptomCodeshttp://hl7.org/fhir/ValueSet/manifestation-or-symptom from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
con-1 | error | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.exists() | |
con-2 | error | Condition.evidence | evidence SHALL have code or details : code.exists() or detail.exists() | |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from LTCCondition
Other representations of profile: CSV, Excel, Schematron