{ "resourceType": "StructureDefinition", "id": "observation-clinemr", "text": { "status": "extensions", "div": "

Generated Narrative: StructureDefinition observation-clinemr

\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
NameFlagsCard.TypeDescription & Constraints\"doco\"
\".\"\".\" Observation TWCoreObservationLaboratoryResult
\".\"\".\"\".\" basedOn 0..*Reference(服務請求(ServiceRequest ClinEMR))依據的照護計畫／提議／醫令
\".\"\".\"\".\" partOf 0..*Reference(MedicationAdministration | TW Core MedicationDispense | TW Core MedicationStatement | 西醫-處置或手術(Procedure MCR) | Immunization | TW Core ImagingStudy)此檢驗檢查是哪個參照事件的一部分
\".\"\".\"\".\" status 1..1coderegistered ｜ preliminary ｜ final ｜ amended +
Required Pattern: final
\".\"\".\"\".\" category 1..1CodeableConcept概念（concept）－參照一個專門術語或只是純文字。
Required Pattern: At least the following
\".\"\".\"\".\"\".\" coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
\".\"\".\"\".\"\".\"\".\" system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
\".\"\".\"\".\"\".\"\".\" code1..1codeSymbol in syntax defined by the system
Fixed Value: laboratory
\".\"\".\"\".\"\".\" coding S1..1CodingCode defined by a terminology system
\".\"\".\"\".\" code 1..1CodeableConceptTW概念(concept)－參照一個專門術語或只是純文字。[應填入門診病摘健保檢驗檢查代碼Test NHICode(code)及檢驗檢查名稱Test Name(text)]
\".\"\".\"\".\"\".\" text 1..1string概念的文字表示法
\".\"\".\"\".\" subject 1..1Reference(病人資料(Patient ClinEMR))檢驗檢查有關的對象及（或）事物
\".\"\".\"\".\" encounter 0..1Reference(就醫事件(Encounter ClinEMR))檢驗檢查是哪一次就醫時執行的
\".\"\".\"\".\" Slices for effective[x] 1..1dateTime, Period, Timing, instant檢驗檢查執行日期或時間區間
Slice: Unordered, Open by type:$this
\".\"\".\"\".\"\".\" effective[x]:effectiveDateTime S0..1dateTime檢驗檢查執行日期或時間區間。[應填入門診病摘之檢查日期Exam Date]
\".\"\".\"\".\" issued S1..1instant[應填入檢驗檢查完成的日期或時間]
\".\"\".\"\".\" performer 1..1Reference(檢驗檢查機構(OrganizationInspection ClinEMR))[應填入檢驗檢查執行醫事機構代碼Exam Hospital ID與檢驗檢查執行醫事機構名稱Exam Hospital Name]
\".\"\".\"\".\" value[x] 0..1Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period[應填入門診病摘檢驗檢查結果值Test Result及檢驗檢查結果單位Result Unit]。
\".\"\".\"\".\" interpretation S0..*CodeableConceptTW高、低、正常等。[應填入門診病摘檢驗檢查結果判斷註記Result Flag]
\".\"\".\"\".\" note S0..*Annotation關於此檢驗檢查之解說[應填入門診病摘檢驗檢查結果備註說明Result Comment]
\".\"\".\"\".\" hasMember 0..*Reference(檢驗檢查(Observation ClinEMR) | QuestionnaireResponse | MolecularSequence)屬於此組檢驗檢查的相關Resource
\".\"\".\"\".\" derivedFrom 0..*Reference(文件參照(DocumentReference ClinEMR) | TW Core ImagingStudy | TW Core Media | QuestionnaireResponse | 檢驗檢查(Observation ClinEMR) | MolecularSequence)檢驗檢查源自哪些相關測量
\".\"\".\"\".\" component 0..*BackboneElement組成之（部分）檢驗檢查的檢驗結果。若為檢驗套組此項目為必填。
\".\"\".\"\".\"\".\" code 1..1CodeableConceptTW[應填入健保檢驗檢查代碼Test NHICode(Code)與檢驗檢查名稱Test Name(text)]
\".\"\".\"\".\"\".\"\".\" text 1..1string概念的文字表示法
\".\"\".\"\".\"\".\" value[x] 0..1Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period[應填入門診病摘組成之檢驗檢查結果值Test Result及檢驗檢查結果單位Result Unit]
\".\"\".\"\".\"\".\" interpretation S0..*CodeableConceptTW高、低、正常等。[應填入門診病摘檢驗檢查結果判斷註記Result Flag]
\".\"\".\"\".\"\".\"\".\" text 0..1string[應填入門診病摘檢驗檢查結果備註說明Result Comment]

\"doco\" Documentation for this format
" }, "url": "https://fhir.cohesiondata.com/clinemr/StructureDefinition/observation-clinemr", "version": "1.0.0", "name": "ObservationClinEMR", "title": "檢驗檢查(Observation ClinEMR)", "status": "active", "date": "2024-10-06T09:51:07+00:00", "publisher": "睿傳數據", "contact": [ { "name": "睿傳數據", "telecom": [ { "system": "url", "value": "https://www.cohesiondata.com/" } ] } ], "description": "此檢驗檢查(Observation ClinEMR)Profile說明本IG如何進一步定義臺灣核心-檢驗檢查(TW Core Observation Laboratory Result)Profile以呈現西醫/牙醫/中醫診所門診病摘之檢驗檢查的詳細資料。", "fhirVersion": "4.0.1", "mapping": [ { "identity": "workflow", "uri": "http://hl7.org/fhir/workflow", "name": "Workflow Pattern" }, { "identity": "sct-concept", "uri": "http://snomed.info/conceptdomain", "name": "SNOMED CT Concept Domain Binding" }, { "identity": "v2", "uri": "http://hl7.org/v2", "name": "HL7 v2 Mapping" }, { "identity": "rim", "uri": "http://hl7.org/v3", "name": "RIM Mapping" }, { "identity": "w5", "uri": "http://hl7.org/fhir/fivews", "name": "FiveWs Pattern Mapping" }, { "identity": "sct-attr", "uri": "http://snomed.org/attributebinding", "name": "SNOMED CT Attribute Binding" } ], "kind": "resource", "abstract": false, "type": "Observation", "baseDefinition": "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Observation-laboratoryResult-twcore", "derivation": "constraint", "snapshot": {}, "differential": { "element": [ { "id": "Observation.basedOn", "path": "Observation.basedOn", "type": [ { "code": "Reference", "targetProfile": [ "https://fhir.cohesiondata.com/clinemr/StructureDefinition/servicerequest-clinemr" ] } ] }, { "id": "Observation.partOf", "path": "Observation.partOf", "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/MedicationAdministration", "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/MedicationDispense-twcore", "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/MedicationStatement-twcore", "https://fhir.cohesiondata.com/clinemr/StructureDefinition/procedure-mcr", "http://hl7.org/fhir/StructureDefinition/Immunization", "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/ImagingStudy-twcore" ] } ] }, { "id": "Observation.status", "path": "Observation.status", "patternCode": "final" }, { "id": "Observation.category", "path": "Observation.category", "min": 1, "max": "1", "patternCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory" } ] } }, { "id": "Observation.category.coding", "path": "Observation.category.coding", "min": 1, "max": "1", "mustSupport": true }, { "id": "Observation.code", "path": "Observation.code", "short": "概念(concept)－參照一個專門術語或只是純文字。[應填入門診病摘健保檢驗檢查代碼Test NHICode(code)及檢驗檢查名稱Test Name(text)]" }, { "id": "Observation.code.text", "path": "Observation.code.text", "min": 1 }, { "id": "Observation.subject", "path": "Observation.subject", "type": [ { "code": "Reference", "targetProfile": [ "https://fhir.cohesiondata.com/clinemr/StructureDefinition/patient-clinemr" ] } ] }, { "id": "Observation.encounter", "path": "Observation.encounter", "type": [ { "code": "Reference", "targetProfile": [ "https://fhir.cohesiondata.com/clinemr/StructureDefinition/encounter-clinemr" ] } ] }, { "id": "Observation.effective[x]", "path": "Observation.effective[x]", "slicing": { "discriminator": [ { "type": "type", "path": "$this" } ], "ordered": false, "rules": "open" } }, { "id": "Observation.effective[x]:effectiveDateTime", "path": "Observation.effective[x]", "sliceName": "effectiveDateTime", "short": "檢驗檢查執行日期或時間區間。[應填入門診病摘之檢查日期Exam Date]", "min": 0, "max": "1", "type": [ { "code": "dateTime" } ], "mustSupport": true }, { "id": "Observation.issued", "path": "Observation.issued", "short": "[應填入檢驗檢查完成的日期或時間]", "min": 1, "mustSupport": true }, { "id": "Observation.performer", "path": "Observation.performer", "short": "[應填入檢驗檢查執行醫事機構代碼Exam Hospital ID與檢驗檢查執行醫事機構名稱Exam Hospital Name]", "min": 1, "max": "1", "type": [ { "code": "Reference", "targetProfile": [ "https://fhir.cohesiondata.com/clinemr/StructureDefinition/organizationinspection-clinemr" ] } ] }, { "id": "Observation.value[x]", "path": "Observation.value[x]", "short": "[應填入門診病摘檢驗檢查結果值Test Result及檢驗檢查結果單位Result Unit]。" }, { "id": "Observation.interpretation", "path": "Observation.interpretation", "short": "高、低、正常等。[應填入門診病摘檢驗檢查結果判斷註記Result Flag]", "mustSupport": true }, { "id": "Observation.note", "path": "Observation.note", "short": "關於此檢驗檢查之解說[應填入門診病摘檢驗檢查結果備註說明Result Comment]", "mustSupport": true }, { "id": "Observation.hasMember", "path": "Observation.hasMember", "type": [ { "code": "Reference", "targetProfile": [ "https://fhir.cohesiondata.com/clinemr/StructureDefinition/observation-clinemr", "http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse", "http://hl7.org/fhir/StructureDefinition/MolecularSequence" ] } ] }, { "id": "Observation.derivedFrom", "path": "Observation.derivedFrom", "type": [ { "code": "Reference", "targetProfile": [ "https://fhir.cohesiondata.com/clinemr/StructureDefinition/documentreference-clinemr", "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/ImagingStudy-twcore", "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Media-twcore", "http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse", "https://fhir.cohesiondata.com/clinemr/StructureDefinition/observation-clinemr", "http://hl7.org/fhir/StructureDefinition/MolecularSequence" ] } ] }, { "id": "Observation.component", "path": "Observation.component", "short": "組成之（部分）檢驗檢查的檢驗結果。若為檢驗套組此項目為必填。" }, { "id": "Observation.component.code", "path": "Observation.component.code", "short": "[應填入健保檢驗檢查代碼Test NHICode(Code)與檢驗檢查名稱Test Name(text)]" }, { "id": "Observation.component.code.text", "path": "Observation.component.code.text", "min": 1 }, { "id": "Observation.component.value[x]", "path": "Observation.component.value[x]", "short": "[應填入門診病摘組成之檢驗檢查結果值Test Result及檢驗檢查結果單位Result Unit]" }, { "id": "Observation.component.interpretation", "path": "Observation.component.interpretation", "short": "高、低、正常等。[應填入門診病摘檢驗檢查結果判斷註記Result Flag]", "mustSupport": true }, { "id": "Observation.component.interpretation.text", "path": "Observation.component.interpretation.text", "short": "[應填入門診病摘檢驗檢查結果備註說明Result Comment]" } ] } }