{ "resourceType": "StructureDefinition", "id": "SatuSehatClinicalImpression", "url": "https://fhir.kemkes.go.id/r4/StructureDefinition/ClinicalImpression", "name": "SatuSehatClinicalImpression", "title": "Satu Sehat Clinical Impression", "status": "active", "date": "2024-01-01", "description": "Defines the ID Core constraints and extension on the record of a clinical assessment performed to determine what problem(s) may affect the patient and before planning the treatments or management strategies that are best to manage a patient's condition.", "fhirVersion": "4.0.1", "kind": "resource", "abstract": false, "type": "ClinicalImpression", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/ClinicalImpression", "derivation": "constraint", "snapshot": { "element": [ { "id": "ClinicalImpression", "path": "ClinicalImpression", "short": "A clinical assessment performed when planning treatments and management strategies for a patient", "definition": "A record of a clinical assessment performed to determine what problem(s) may affect the patient and before planning the treatments or management strategies that are best to manage a patient's condition. Assessments are often 1:1 with a clinical consultation / encounter, but this varies greatly depending on the clinical workflow. This resource is called \"ClinicalImpression\" rather than \"ClinicalAssessment\" to avoid confusion with the recording of assessment tools such as Apgar score.", "min": 0, "max": "*", "base": { "path": "ClinicalImpression", "min": 0, "max": "*" }, "constraint": [ { "key": "dom-2", "severity": "error", "human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources", "expression": "contained.contained.empty()", "xpath": "not(parent::f:contained and f:contained)", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-4", "severity": "error", "human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated", "expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()", "xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-3", "severity": "error", "human": "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", "expression": "contained.where(((id.exists() and ('#'+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(uri) = '#').exists()).not()).trace('unmatched', id).empty()", "xpath": "not(exists(for $contained in f:contained return $contained[not(exists(parent::*/descendant::f:reference/@value=concat('#', $contained/*/f:id/@value)) or exists(descendant::f:reference[@value='#']))]))", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice", "valueBoolean": true }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice-explanation", "valueMarkdown": "When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time." } ], "key": "dom-6", "severity": "warning", "human": "A resource should have narrative for robust management", "expression": "text.`div`.exists()", "xpath": "exists(f:text/h:div)", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-5", "severity": "error", "human": "If a resource is contained in another resource, it SHALL NOT have a security label", "expression": "contained.meta.security.empty()", "xpath": "not(exists(f:contained/*/f:meta/f:security))", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" } ], "mustSupport": false, "isModifier": false, "mapping": [ { "identity": "rim", "map": "Entity. Role, or Act" }, { "identity": "workflow", "map": "Event" }, { "identity": "v2", "map": "Partial mapping for problem evaluation" }, { "identity": "w5", "map": "clinical.general" } ] }, { "id": "ClinicalImpression.id", "path": "ClinicalImpression.id", "short": "Logical id of this artifact", "definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.", "comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.", "min": 0, "max": "1", "base": { "path": "Resource.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "id" } ], "code": "id" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ClinicalImpression.meta", "path": "ClinicalImpression.meta", "short": "Metadata about the resource", "definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.", "min": 0, "max": "1", "base": { "path": "Resource.meta", "min": 0, "max": "1" }, "type": [ { "code": "Meta" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ClinicalImpression.implicitRules", "path": "ClinicalImpression.implicitRules", "short": "A set of rules under which this content was created", "definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.", "comment": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.", "min": 0, "max": "1", "base": { "path": "Resource.implicitRules", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": true, "isModifierReason": "This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ClinicalImpression.language", "path": "ClinicalImpression.language", "short": "Language of the resource content", "definition": "The base language in which the resource is written.", "comment": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).", "min": 0, "max": "1", "base": { "path": "Resource.language", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet", "valueCanonical": "http://hl7.org/fhir/ValueSet/all-languages" }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Language" } ], "strength": "preferred", "description": "IETF language tag", "valueSet": "http://hl7.org/fhir/ValueSet/languages" }, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ClinicalImpression.text", "path": "ClinicalImpression.text", "short": "Text summary of the resource, for human interpretation", "definition": "A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.", "comment": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded information is added later.", "alias": [ "narrative", "html", "xhtml", "display" ], "min": 0, "max": "1", "base": { "path": "DomainResource.text", "min": 0, "max": "1" }, "type": [ { "code": "Narrative" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" }, { "identity": "rim", "map": "Act.text?" } ] }, { "id": "ClinicalImpression.contained", "path": "ClinicalImpression.contained", "short": "Contained, inline Resources", "definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.", "comment": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.", "alias": [ "inline resources", "anonymous resources", "contained resources" ], "min": 0, "max": "*", "base": { "path": "DomainResource.contained", "min": 0, "max": "*" }, "type": [ { "code": "Resource" } ], "constraint": [ { "key": "dom-r4b", "severity": "warning", "human": "Containing new R4B resources within R4 resources may cause interoperability issues if instances are shared with R4 systems", "expression": "($this is Citation or $this is Evidence or $this is EvidenceReport or $this is EvidenceVariable or $this is MedicinalProductDefinition or $this is PackagedProductDefinition or $this is AdministrableProductDefinition or $this is Ingredient or $this is ClinicalUseDefinition or $this is RegulatedAuthorization or $this is SubstanceDefinition or $this is SubscriptionStatus or $this is SubscriptionTopic) implies (%resource is Citation or %resource is Evidence or %resource is EvidenceReport or %resource is EvidenceVariable or %resource is MedicinalProductDefinition or %resource is PackagedProductDefinition or %resource is AdministrableProductDefinition or %resource is Ingredient or %resource is ClinicalUseDefinition or %resource is RegulatedAuthorization or %resource is SubstanceDefinition or %resource is SubscriptionStatus or %resource is SubscriptionTopic)", "xpath": "not(f:Citation|f:Evidence|f:EvidenceReport|f:EvidenceVariable|f:MedicinalProductDefinition|f:PackagedProductDefinition|f:AdministrableProductDefinition|f:Ingredient|f:ClinicalUseDefinition|f:RegulatedAuthorization|f:SubstanceDefinition|f:SubscriptionStatus|f:SubscriptionTopic) or not(parent::f:Citation|parent::f:Evidence|parent::f:EvidenceReport|parent::f:EvidenceVariable|parent::f:MedicinalProductDefinition|parent::f:PackagedProductDefinition|parent::f:AdministrableProductDefinition|parent::f:Ingredient|parent::f:ClinicalUseDefinition|parent::f:RegulatedAuthorization|parent::f:SubstanceDefinition|f:SubscriptionStatus|f:SubscriptionTopic)", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "Entity. Role, or Act" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ClinicalImpression.extension", "path": "ClinicalImpression.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "DomainResource.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ClinicalImpression.modifierExtension", "path": "ClinicalImpression.modifierExtension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Extensions that cannot be ignored", "definition": "May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "DomainResource.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mustSupport": false, "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them", "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ClinicalImpression.identifier", "path": "ClinicalImpression.identifier", "short": "Business identifier", "definition": "Berisi satu atau lebih daftar data ID internal faskes untuk data clinical impression yang setiap datanya direpresentasikan dengan tipe data Identifier.", "comment": "This is a business identifier, not a resource identifier (see [discussion](resource.html#identifiers)). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.", "requirements": "Allows identification of the clinical impression as it is known by various participating systems and in a way that remains consistent across servers.", "min": 0, "max": "1", "base": { "path": "ClinicalImpression.identifier", "min": 0, "max": "*" }, "type": [ { "code": "Identifier" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" }, { "identity": "workflow", "map": "Event.identifier" }, { "identity": "w5", "map": "FiveWs.identifier" }, { "identity": "v2", "map": "PID-3" } ] }, { "id": "ClinicalImpression.identifier.id", "path": "ClinicalImpression.identifier.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "id" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ClinicalImpression.identifier.extension", "path": "ClinicalImpression.identifier.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ClinicalImpression.identifier.use", "path": "ClinicalImpression.identifier.use", "short": "usual | official | temp | secondary | old (If known)", "definition": "Berisi data dengan tipe data code, yang nilainya mengacu pada data terminologi IdentifierUse.", "comment": "Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.", "requirements": "Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.", "min": 0, "max": "1", "base": { "path": "Identifier.use", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": true, "isModifierReason": "This is labeled as \"Is Modifier\" because applications should not mistake a temporary id for a permanent one.", "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/build/StructureDefinition/binding-definition", "valueString": "Identifies the purpose for this identifier, if known ." }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "IdentifierUse" } ], "strength": "required", "valueSet": "http://hl7.org/fhir/ValueSet/identifier-use|4.3.0" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "Role.code or implied by context" } ] }, { "id": "ClinicalImpression.identifier.type", "path": "ClinicalImpression.identifier.type", "short": "Description of identifier", "definition": "A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.", "comment": "This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.", "requirements": "Allows users to make use of identifiers when the identifier system is not known.", "min": 0, "max": "1", "base": { "path": "Identifier.type", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/build/StructureDefinition/binding-definition", "valueString": "A coded type for an identifier that can be used to determine which identifier to use for a specific purpose." }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "IdentifierType" } ], "strength": "extensible", "valueSet": "http://hl7.org/fhir/ValueSet/identifier-type" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "v2", "map": "CX.5" }, { "identity": "rim", "map": "Role.code or implied by context" } ] }, { "id": "ClinicalImpression.identifier.system", "path": "ClinicalImpression.identifier.system", "short": "The namespace for the identifier value", "definition": "Berisi data yang nilainya memiliki format: http://sys-ids.kemkes.go.id/clinicalimpression/{{organization-ihs-number}}", "comment": "Identifier.system is always case sensitive.", "requirements": "There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.", "min": 0, "max": "1", "base": { "path": "Identifier.system", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "example": [ { "label": "General", "valueUri": "http://www.acme.com/identifiers/patient" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX.4 / EI-2-4" }, { "identity": "rim", "map": "II.root or Role.id.root" }, { "identity": "servd", "map": "./IdentifierType" } ] }, { "id": "ClinicalImpression.identifier.value", "path": "ClinicalImpression.identifier.value", "short": "The value that is unique", "definition": "Berisi kode atau ID lokal yang disimpan di sistem internal masing-masing organisasi.", "comment": "If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the [Rendered Value extension](extension-rendered-value.html). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.", "min": 0, "max": "1", "base": { "path": "Identifier.value", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "example": [ { "label": "General", "valueString": "123456" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX.1 / EI.1" }, { "identity": "rim", "map": "II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)" }, { "identity": "servd", "map": "./Value" } ] }, { "id": "ClinicalImpression.identifier.period", "path": "ClinicalImpression.identifier.period", "short": "Time period when id is/was valid for use", "definition": "Time period during which identifier is/was valid for use.", "comment": "A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. \"the patient was an inpatient of the hospital for this time range\") or one value from the range applies (e.g. \"give to the patient between these two times\").\n\nPeriod is not used for a duration (a measure of elapsed time). See [Duration](datatypes.html#Duration).", "min": 0, "max": "1", "base": { "path": "Identifier.period", "min": 0, "max": "1" }, "type": [ { "code": "Period" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "per-1", "severity": "error", "human": "If present, start SHALL have a lower value than end", "expression": "start.hasValue().not() or end.hasValue().not() or (start <= end)", "xpath": "not(exists(f:start/@value)) or not(exists(f:end/@value)) or (xs:dateTime(f:start/@value) <= xs:dateTime(f:end/@value))", "source": "http://hl7.org/fhir/StructureDefinition/Period" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "DR" }, { "identity": "rim", "map": "IVL[lowClosed=\"true\" and highClosed=\"true\"] or URG[lowClosed=\"true\" and highClosed=\"true\"]" }, { "identity": "v2", "map": "CX.7 + CX.8" }, { "identity": "rim", "map": "Role.effectiveTime or implied by context" }, { "identity": "servd", "map": "./StartDate and ./EndDate" } ] }, { "id": "ClinicalImpression.identifier.assigner", "path": "ClinicalImpression.identifier.assigner", "short": "Organization that issued id (may be just text)", "definition": "Organization that issued/manages the identifier.", "comment": "The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.", "min": 0, "max": "1", "base": { "path": "Identifier.assigner", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "v2", "map": "CX.4 / (CX.4,CX.9,CX.10)" }, { "identity": "rim", "map": "II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper" }, { "identity": "servd", "map": "./IdentifierIssuingAuthority" } ] }, { "id": "ClinicalImpression.status", "path": "ClinicalImpression.status", "short": "in-progress | completed | entered-in-error", "definition": "Digunakan untuk mengidentifikasi status alur kerja penilaian atau asesmen yang setiap datanya direpresentasikan dengan tipe data code, yang nilainya mengacu pada data terminologi EventStatus.", "comment": "This element is labeled as a modifier because the status contains the code entered-in-error that marks the clinical impression as not currently valid.", "min": 1, "max": "1", "base": { "path": "ClinicalImpression.status", "min": 1, "max": "1" }, "type": [ { "code": "code" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": true, "isModifierReason": "This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid", "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ClinicalImpressionStatus" } ], "strength": "required", "description": "The workflow state of a clinical impression.", "valueSet": "http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.3.0" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.status" }, { "identity": "w5", "map": "FiveWs.status" }, { "identity": "v2", "map": "PRB-14" } ] }, { "id": "ClinicalImpression.statusReason", "path": "ClinicalImpression.statusReason", "short": "Reason for current status", "definition": "Berisi informasi terkait alasan status dari asesmen dengan tipe data CodeableConcept.", "comment": "This is generally only used for \"exception\" statuses such as \"not-done\", \"suspended\" or \"cancelled\".\n\n[distinct reason codes for different statuses can be enforced using invariants if they are universal bindings].", "alias": [ "Suspended Reason", "Cancelled Reason" ], "min": 0, "max": "1", "base": { "path": "ClinicalImpression.statusReason", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ClinicalImpressionStatusReason" } ], "strength": "example", "description": "Codes identifying the reason for the current state of a clinical impression." }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "workflow", "map": "Event.statusReason" }, { "identity": "rim", "map": ".inboundRelationship[typeCode=SUBJ].source[classCode=CACT, moodCode=EVN].reasonCOde" } ] }, { "id": "ClinicalImpression.statusReason.id", "path": "ClinicalImpression.statusReason.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "id" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ClinicalImpression.statusReason.extension", "path": "ClinicalImpression.statusReason.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ClinicalImpression.statusReason.coding", "path": "ClinicalImpression.statusReason.coding", "short": "Code defined by a terminology system", "definition": "Berisi data kode alasan status dari asesmen dengan tipe data Coding.", "comment": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.", "requirements": "Allows for alternative encodings within a code system, and translations to other code systems.", "min": 0, "max": "*", "base": { "path": "CodeableConcept.coding", "min": 0, "max": "*" }, "type": [ { "code": "Coding" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE subset one of the sets of component 1-3 or 4-6" }, { "identity": "rim", "map": "CV" }, { "identity": "orim", "map": "fhir:Coding rdfs:subClassOf dt:CDCoding" }, { "identity": "v2", "map": "C*E.1-8, C*E.10-22" }, { "identity": "rim", "map": "union(., ./translation)" }, { "identity": "orim", "map": "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding" } ] }, { "id": "ClinicalImpression.statusReason.text", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "ClinicalImpression.statusReason.text", "short": "Plain text representation of the concept", "definition": "Berisi alasan status asesmen dengan tipe data text.", "comment": "Very often the text is the same as a displayName of one of the codings.", "requirements": "The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.", "min": 0, "max": "1", "base": { "path": "CodeableConcept.text", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "C*E.9. But note many systems use C*E.2 for this" }, { "identity": "rim", "map": "./originalText[mediaType/code=\"text/plain\"]/data" }, { "identity": "orim", "map": "fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText" } ] }, { "id": "ClinicalImpression.code", "path": "ClinicalImpression.code", "short": "Kind of assessment performed", "definition": "Berisi informasi mengenai kategori dari asesmen klinis yang dilakukan dengan tipe data CodeableConcept.", "comment": "This is present as a place-holder only and may be removed based on feedback/work group opinion.", "alias": [ "type" ], "min": 0, "max": "1", "base": { "path": "ClinicalImpression.code", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ClinicalImpressionCode" } ], "strength": "example", "description": "Identifies categories of clinical impressions. This is a place-holder only. It may be removed." }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "workflow", "map": "Event.code" }, { "identity": "w5", "map": "FiveWs.what[x]" } ] }, { "id": "ClinicalImpression.code.id", "path": "ClinicalImpression.code.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "id" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ClinicalImpression.code.extension", "path": "ClinicalImpression.code.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ClinicalImpression.code.coding", "path": "ClinicalImpression.code.coding", "short": "Code defined by a terminology system", "definition": "Berisi data kode kategori dari asesmen klinis yang sedang dilakukan dengan tipe data Coding.", "comment": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.", "requirements": "Allows for alternative encodings within a code system, and translations to other code systems.", "min": 0, "max": "*", "base": { "path": "CodeableConcept.coding", "min": 0, "max": "*" }, "type": [ { "code": "Coding" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE subset one of the sets of component 1-3 or 4-6" }, { "identity": "rim", "map": "CV" }, { "identity": "orim", "map": "fhir:Coding rdfs:subClassOf dt:CDCoding" }, { "identity": "v2", "map": "C*E.1-8, C*E.10-22" }, { "identity": "rim", "map": "union(., ./translation)" }, { "identity": "orim", "map": "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding" } ] }, { "id": "ClinicalImpression.code.text", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "ClinicalImpression.code.text", "short": "Plain text representation of the concept", "definition": "Berisi informasi mengenai kategori dari asesmen klinis yang dilakukan dengan tipe data text.", "comment": "Very often the text is the same as a displayName of one of the codings.", "requirements": "The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.", "min": 0, "max": "1", "base": { "path": "CodeableConcept.text", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "C*E.9. But note many systems use C*E.2 for this" }, { "identity": "rim", "map": "./originalText[mediaType/code=\"text/plain\"]/data" }, { "identity": "orim", "map": "fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText" } ] }, { "id": "ClinicalImpression.description", "path": "ClinicalImpression.description", "short": "Why/how the assessment was performed", "definition": "Berisi Rangkuman konteks dan atau penyebab dilakukannya asesmen, kenapa dan di mana dilakukan, dan kondisi pasien apa yang mendasari dilakukannya suatu asesmen dengan tipe data string.", "comment": "Note that FHIR strings SHALL NOT exceed 1MB in size", "min": 0, "max": "1", "base": { "path": "ClinicalImpression.description", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ClinicalImpression.subject", "path": "ClinicalImpression.subject", "short": "Patient or group assessed", "definition": "Berkaitan dengan subjek dari ClinicalImpression itu sendiri yang pada bagian ini berisi data dengan tipe data Reference yang direferensikan ke data yang tersimpan di resource Patient | Group.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "requirements": "Group is typically for veterinary and/or public health purposes.", "min": 1, "max": "1", "base": { "path": "ClinicalImpression.subject", "min": 1, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/Group" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.subject" }, { "identity": "w5", "map": "FiveWs.subject[x]" }, { "identity": "v2", "map": "PID-3" }, { "identity": "w5", "map": "FiveWs.subject" } ] }, { "id": "ClinicalImpression.subject.id", "path": "ClinicalImpression.subject.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "id" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ClinicalImpression.subject.extension", "path": "ClinicalImpression.subject.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ClinicalImpression.subject.reference", "path": "ClinicalImpression.subject.reference", "short": "Literal reference, Relative, internal or absolute URL", "definition": "Berisi subjek dari ClinicalImpression, yang diisikan dengan ID Patient.", "comment": "Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure \"/[type]/[id]\" then it should be assumed that the reference is to a FHIR RESTful server.", "min": 0, "max": "1", "base": { "path": "Reference.reference", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1", "ref-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ClinicalImpression.subject.type", "path": "ClinicalImpression.subject.type", "short": "Type the reference refers to (e.g. \"Patient\")", "definition": "The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.\n\nThe type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. \"Patient\" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).", "comment": "This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.", "min": 0, "max": "1", "base": { "path": "Reference.type", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/build/StructureDefinition/binding-definition", "valueString": "Aa resource (or, for logical models, the URI of the logical model)." }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "FHIRResourceTypeExt" } ], "strength": "extensible", "valueSet": "http://hl7.org/fhir/ValueSet/resource-types" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ClinicalImpression.subject.identifier", "path": "ClinicalImpression.subject.identifier", "short": "Logical reference, when literal reference is not known", "definition": "An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.", "comment": "When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. \n\nWhen both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference\n\nApplications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.\n\nReference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).", "min": 0, "max": "1", "base": { "path": "Reference.identifier", "min": 0, "max": "1" }, "type": [ { "code": "Identifier" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" }, { "identity": "rim", "map": ".identifier" } ] }, { "id": "ClinicalImpression.subject.display", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "ClinicalImpression.subject.display", "short": "Text alternative for the resource", "definition": "Berisi Nama pasien dalam bentuk free text.", "comment": "This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.", "min": 0, "max": "1", "base": { "path": "Reference.display", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ClinicalImpression.encounter", "path": "ClinicalImpression.encounter", "short": "Encounter created as part of", "definition": "Berisi informasi terkait kunjungan di mana asesmen dilakukan dengan tipe data Reference, yang direferensikan ke data yang tersimpan di resource Encounter.", "comment": "This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.", "min": 1, "max": "1", "base": { "path": "ClinicalImpression.encounter", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Encounter" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.context" }, { "identity": "w5", "map": "FiveWs.context" } ] }, { "id": "ClinicalImpression.effective[x]", "path": "ClinicalImpression.effective[x]", "slicing": { "discriminator": [ { "type": "type", "path": "$this" } ], "ordered": false, "rules": "open" }, "short": "Time of assessment", "definition": "Berisi informasi mengenai waktu dilakukannya asesmen.", "comment": "This SHOULD be accurate to at least the minute, though some assessments only have a known date.", "min": 0, "max": "1", "base": { "path": "ClinicalImpression.effective[x]", "min": 0, "max": "1" }, "type": [ { "code": "dateTime" }, { "code": "Period" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.occurrence[x]" }, { "identity": "w5", "map": "FiveWs.done[x]" }, { "identity": "v2", "map": "PRB-2" } ] }, { "id": "ClinicalImpression.effective[x]:effectiveDateTime", "path": "ClinicalImpression.effective[x]", "sliceName": "effectiveDateTime", "short": "Time of assessment", "definition": "Berisi data mengenai kapan asesmen dilakukan dengan tipe data dateTime, dengan format yang diperbolehkan YYYY, YYYY-MM, YYYY-MM-DD atau YYYY-MM-DDThh:mm:ss+zz:zz.", "comment": "This SHOULD be accurate to at least the minute, though some assessments only have a known date.", "min": 0, "max": "1", "base": { "path": "ClinicalImpression.effective[x]", "min": 0, "max": "1" }, "type": [ { "code": "dateTime" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.occurrence[x]" }, { "identity": "w5", "map": "FiveWs.done[x]" }, { "identity": "v2", "map": "PRB-2" } ] }, { "id": "ClinicalImpression.effective[x]:effectivePeriod", "path": "ClinicalImpression.effective[x]", "sliceName": "effectivePeriod", "short": "Time of assessment", "definition": "Berisi data waktu dari asesmen dimulai sampai selesai (arrived to finished) dengan tipe data Period.", "comment": "This SHOULD be accurate to at least the minute, though some assessments only have a known date.", "min": 0, "max": "1", "base": { "path": "ClinicalImpression.effective[x]", "min": 0, "max": "1" }, "type": [ { "code": "Period" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.occurrence[x]" }, { "identity": "w5", "map": "FiveWs.done[x]" }, { "identity": "v2", "map": "PRB-2" } ] }, { "id": "ClinicalImpression.effective[x]:effectivePeriod.id", "path": "ClinicalImpression.effective[x].id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "id" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ClinicalImpression.effective[x]:effectivePeriod.extension", "path": "ClinicalImpression.effective[x].extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ClinicalImpression.effective[x]:effectivePeriod.start", "path": "ClinicalImpression.effective[x].start", "short": "Starting time with inclusive boundary", "definition": "Diisi dengan waktu mulai, sama dengan waktu asesmen pasien dalam format YYYY-MM-DD.", "comment": "If the low element is missing, the meaning is that the low boundary is not known.", "min": 0, "max": "1", "base": { "path": "Period.start", "min": 0, "max": "1" }, "type": [ { "code": "dateTime" } ], "condition": [ "ele-1", "per-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "DR.1" }, { "identity": "rim", "map": "./low" } ] }, { "id": "ClinicalImpression.effective[x]:effectivePeriod.end", "path": "ClinicalImpression.effective[x].end", "short": "End time with inclusive boundary, if not ongoing", "definition": "Diisi dengan waktu selesai, sama dengan waktu selesai asesmen pasien dalam format YYYY-MM-DD.", "comment": "The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.", "min": 0, "max": "1", "base": { "path": "Period.end", "min": 0, "max": "1" }, "type": [ { "code": "dateTime" } ], "meaningWhenMissing": "If the end of the period is missing, it means that the period is ongoing", "condition": [ "ele-1", "per-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "DR.2" }, { "identity": "rim", "map": "./high" } ] }, { "id": "ClinicalImpression.date", "path": "ClinicalImpression.date", "short": "When the assessment was documented", "definition": "Merupakan waktu data asesmen dicatat atau didokumentasikan. Pada bagian ini berisi data dengan tipe data dateTime, dengan format yang diperbolehkan YYYY, YYYY-MM, YYYY-MM-DD atau YYYY-MM-DDThh:mm:ss+zz:zz.", "min": 0, "max": "1", "base": { "path": "ClinicalImpression.date", "min": 0, "max": "1" }, "type": [ { "code": "dateTime" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "w5", "map": "FiveWs.recorded" } ] }, { "id": "ClinicalImpression.assessor", "path": "ClinicalImpression.assessor", "short": "The clinician performing the assessment", "definition": "Berisi informasi mengenai klinisi yang melakukan asesmen. Pada bagian ini berisi data dengan tipe data Reference yang direferensikan ke data yang tersimpan di resource Practitioner dan PractitionerRole.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "min": 0, "max": "1", "base": { "path": "ClinicalImpression.assessor", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.performer.actor" }, { "identity": "w5", "map": "FiveWs.author" }, { "identity": "v2", "map": "ROL-4" } ] }, { "id": "ClinicalImpression.previous", "path": "ClinicalImpression.previous", "short": "Reference to last assessment", "definition": "Berisi referensi terhadap asesmen sebelumnya. Pada bagian ini berisi data dengan tipe data Reference yang direferensikan ke data yang tersimpan di resource ClinicalImpression.", "comment": "It is always likely that multiple previous assessments exist for a patient. The point of quoting a previous assessment is that this assessment is relative to it (see resolved).", "min": 0, "max": "1", "base": { "path": "ClinicalImpression.previous", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/ClinicalImpression" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" } ] }, { "id": "ClinicalImpression.problem", "path": "ClinicalImpression.problem", "short": "Relevant impressions of patient state", "definition": "Berisi daftar kondisi atau masalah yang relevan pada pasien. Pada bagian ini berisi data dengan tipe data Reference yang direferensikan ke data yang tersimpan di resource Condition dan AllergyIntolerance.", "comment": "e.g. The patient is a pregnant, has congestive heart failure, has an ‎Adenocarcinoma, and is allergic to penicillin.", "min": 0, "max": "1", "base": { "path": "ClinicalImpression.problem", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Condition", "http://hl7.org/fhir/StructureDefinition/AllergyIntolerance" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "w5", "map": "FiveWs.why[x]" }, { "identity": "v2", "map": "PRB-3 / IAM-7" } ] }, { "id": "ClinicalImpression.investigation", "path": "ClinicalImpression.investigation", "short": "One or more sets of investigations (signs, symptoms, etc.)", "definition": "Berisi satu atau lebih rangkaian pemeriksaan (tanda, gejala, dll.). Pengelompokan investigasi yang sebenarnya sangat bervariasi tergantung pada jenis dan konteks penilaian. Investigasi ini dapat mencakup data yang dihasilkan selama proses penilaian, atau data yang dihasilkan dan dicatat sebelumnya yang berkaitan dengan hasil dengan tipe data BackboneElement.", "min": 0, "max": "1", "base": { "path": "ClinicalImpression.investigation", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ClinicalImpression.investigation.id", "path": "ClinicalImpression.investigation.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "id" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ClinicalImpression.investigation.extension", "path": "ClinicalImpression.investigation.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ClinicalImpression.investigation.modifierExtension", "path": "ClinicalImpression.investigation.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ClinicalImpression.investigation.code", "path": "ClinicalImpression.investigation.code", "short": "A name/code for the set", "definition": "Berisi kelompok nama atau kode investigasi yang dilakukan untuk melakukan asesmen. Berkaitan dengan tanda, gejala, klinis, diagnostik namun tidak terbatasi dan kelompok lain seperti riwayat paparan/keluarga/perjalanan/nutrisi dapat digunakan dengan tipe data CodeableConcept.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "min": 1, "max": "1", "base": { "path": "ClinicalImpression.investigation.code", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "InvestigationGroupType" } ], "strength": "example", "description": "A name/code for a set of investigations.", "valueSet": "http://hl7.org/fhir/ValueSet/investigation-sets" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" } ] }, { "id": "ClinicalImpression.investigation.item", "path": "ClinicalImpression.investigation.item", "short": "Record of a specific investigation", "definition": "Berisi catatan terhadap investigasi atau tindakan yang dilakukan untuk asesmen ini. Pada bagian ini berisi data dengan tipe data Reference yang direferensikan ke data yang tersimpan di resource Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media.", "comment": "Most investigations are observations of one kind or another but some other specific types of data collection resources can also be used.", "min": 0, "max": "1", "base": { "path": "ClinicalImpression.investigation.item", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Observation", "http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse", "http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory", "http://hl7.org/fhir/StructureDefinition/DiagnosticReport", "http://hl7.org/fhir/StructureDefinition/RiskAssessment", "http://hl7.org/fhir/StructureDefinition/ImagingStudy", "http://hl7.org/fhir/StructureDefinition/Media" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "v2", "map": "OBX-21" } ] }, { "id": "ClinicalImpression.protocol", "path": "ClinicalImpression.protocol", "short": "Clinical Protocol followed", "definition": "Berisi referensi terhadap protokol klinis tertentu yang diterbitkan yang diikuti selama asesmen ini, dan/atau yang memberikan bukti untuk mendukung diagnosis dengan tipe data uri.", "comment": "see http://en.wikipedia.org/wiki/Uniform_resource_identifier", "min": 0, "max": "1", "base": { "path": "ClinicalImpression.protocol", "min": 0, "max": "*" }, "type": [ { "code": "uri" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ClinicalImpression.summary", "path": "ClinicalImpression.summary", "short": "Summary of the assessment", "definition": "Berisi ringkasan teks dari investigasi dan diagnosis dengan tipe data string.", "comment": "Note that FHIR strings SHALL NOT exceed 1MB in size", "min": 0, "max": "1", "base": { "path": "ClinicalImpression.summary", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "OBX" } ] }, { "id": "ClinicalImpression.finding", "path": "ClinicalImpression.finding", "short": "Possible or likely findings and diagnoses", "definition": "Berisi data temuan atau diagnosis spesifik yang dianggap mungkin atau relevan dengan pengobatan yang sedang berlangsung dengan tipe data BackboneElement.", "min": 0, "max": "1", "base": { "path": "ClinicalImpression.finding", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ClinicalImpression.finding.id", "path": "ClinicalImpression.finding.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "id" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ClinicalImpression.finding.extension", "path": "ClinicalImpression.finding.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ClinicalImpression.finding.modifierExtension", "path": "ClinicalImpression.finding.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ClinicalImpression.finding.itemCodeableConcept", "path": "ClinicalImpression.finding.itemCodeableConcept", "short": "What was found", "definition": "Berisi teks atau kode spesifik terkait temuan atau diagnosis yang relevan terhadap perawatan yang dilakukan dengan tipe data CodeableConcept.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "min": 0, "max": "1", "base": { "path": "ClinicalImpression.finding.itemCodeableConcept", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ConditionKind" } ], "strength": "example", "description": "Identification of the Condition or diagnosis.", "valueSet": "http://hl7.org/fhir/ValueSet/condition-code" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "v2", "map": "OBX" } ] }, { "id": "ClinicalImpression.finding.itemCodeableConcept.id", "path": "ClinicalImpression.finding.itemCodeableConcept.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "id" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ClinicalImpression.finding.itemCodeableConcept.extension", "path": "ClinicalImpression.finding.itemCodeableConcept.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ClinicalImpression.finding.itemCodeableConcept.coding", "path": "ClinicalImpression.finding.itemCodeableConcept.coding", "short": "Code defined by a terminology system", "definition": "Berisi data kode spesifik terkait temuan atau diagnosis yang relevan dengan tipe data Coding yang nilainya mengacu pada data terminologi ICD-10 code versi 2010.", "comment": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.", "requirements": "Allows for alternative encodings within a code system, and translations to other code systems.", "min": 0, "max": "*", "base": { "path": "CodeableConcept.coding", "min": 0, "max": "*" }, "type": [ { "code": "Coding" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE subset one of the sets of component 1-3 or 4-6" }, { "identity": "rim", "map": "CV" }, { "identity": "orim", "map": "fhir:Coding rdfs:subClassOf dt:CDCoding" }, { "identity": "v2", "map": "C*E.1-8, C*E.10-22" }, { "identity": "rim", "map": "union(., ./translation)" }, { "identity": "orim", "map": "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding" } ] }, { "id": "ClinicalImpression.finding.itemCodeableConcept.text", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "ClinicalImpression.finding.itemCodeableConcept.text", "short": "Plain text representation of the concept", "definition": "Berisi teks terkait temuan atau diagnosis yang relevan terhadap perawatan yang dilakukan dengan tipe data text.", "comment": "Very often the text is the same as a displayName of one of the codings.", "requirements": "The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.", "min": 0, "max": "1", "base": { "path": "CodeableConcept.text", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "C*E.9. But note many systems use C*E.2 for this" }, { "identity": "rim", "map": "./originalText[mediaType/code=\"text/plain\"]/data" }, { "identity": "orim", "map": "fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText" } ] }, { "id": "ClinicalImpression.finding.itemReference", "path": "ClinicalImpression.finding.itemReference", "short": "What was found", "definition": "Berisi informasi referensi spesifik terkait temuan atau diagnosis yang relevan terhadap perawatan yang dilakukan. Pada bagian ini berisi data dengan tipe data Reference yang direferensikan ke data yang tersimpan di resource Condition | Observation | Media.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "min": 0, "max": "1", "base": { "path": "ClinicalImpression.finding.itemReference", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Condition", "http://hl7.org/fhir/StructureDefinition/Observation", "http://hl7.org/fhir/StructureDefinition/Media" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "v2", "map": "OBX" } ] }, { "id": "ClinicalImpression.finding.basis", "path": "ClinicalImpression.finding.basis", "short": "Which investigations support finding", "definition": "Berisi informasi mengenai investigasi yang mendukung temuan atau diagnosis dalam bentuk teks dengan tipe data string.", "comment": "Note that FHIR strings SHALL NOT exceed 1MB in size", "min": 0, "max": "1", "base": { "path": "ClinicalImpression.finding.basis", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ClinicalImpression.prognosisCodeableConcept", "path": "ClinicalImpression.prognosisCodeableConcept", "short": "Estimate of likely outcome", "definition": "Berisi informasi perkiraan kemungkinan outcome atau luaran dari kondisi pasien dengan tipe data CodeableConcept.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "min": 1, "max": "1", "base": { "path": "ClinicalImpression.prognosisCodeableConcept", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ClinicalImpressionPrognosis" } ], "strength": "example", "description": "Prognosis or outlook findings.", "valueSet": "http://hl7.org/fhir/ValueSet/clinicalimpression-prognosis" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "v2", "map": "PRB-22" } ] }, { "id": "ClinicalImpression.prognosisCodeableConcept.id", "path": "ClinicalImpression.prognosisCodeableConcept.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "id" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ClinicalImpression.prognosisCodeableConcept.extension", "path": "ClinicalImpression.prognosisCodeableConcept.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "ClinicalImpression.prognosisCodeableConcept.coding", "path": "ClinicalImpression.prognosisCodeableConcept.coding", "short": "Code defined by a terminology system", "definition": "Berisi data kode outcome atau luaran kondisi pasien dengan tipe data Coding.", "comment": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.", "requirements": "Allows for alternative encodings within a code system, and translations to other code systems.", "min": 0, "max": "*", "base": { "path": "CodeableConcept.coding", "min": 0, "max": "*" }, "type": [ { "code": "Coding" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE subset one of the sets of component 1-3 or 4-6" }, { "identity": "rim", "map": "CV" }, { "identity": "orim", "map": "fhir:Coding rdfs:subClassOf dt:CDCoding" }, { "identity": "v2", "map": "C*E.1-8, C*E.10-22" }, { "identity": "rim", "map": "union(., ./translation)" }, { "identity": "orim", "map": "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding" } ] }, { "id": "ClinicalImpression.prognosisCodeableConcept.text", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "ClinicalImpression.prognosisCodeableConcept.text", "short": "Plain text representation of the concept", "definition": "Berisi informasi perkiraan kemungkinan outcome atau luaran dari kondisi pasien dengan tipe data text.", "comment": "Very often the text is the same as a displayName of one of the codings.", "requirements": "The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.", "min": 0, "max": "1", "base": { "path": "CodeableConcept.text", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "C*E.9. But note many systems use C*E.2 for this" }, { "identity": "rim", "map": "./originalText[mediaType/code=\"text/plain\"]/data" }, { "identity": "orim", "map": "fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText" } ] }, { "id": "ClinicalImpression.prognosisReference", "path": "ClinicalImpression.prognosisReference", "short": "RiskAssessment expressing likely outcome", "definition": "Berisi informasi mengenai referensi kemungkinan outcome atau luaran pasien dengan tipe data Reference yang direferensikan ke data yang tersimpan di resource RiskAssessment.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "min": 0, "max": "1", "base": { "path": "ClinicalImpression.prognosisReference", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/RiskAssessment" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" } ] }, { "id": "ClinicalImpression.supportingInfo", "path": "ClinicalImpression.supportingInfo", "short": "Information supporting the clinical impression", "definition": "Berisi informasi mengenai referensi data yang mendukung pada bagian ClinicalImpression ini. Pada bagian ini berisi data dengan tipe data Reference yang direferensikan ke data yang tersimpan di semua resource FHIR yang tersedia.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "min": 0, "max": "1", "base": { "path": "ClinicalImpression.supportingInfo", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" } ] }, { "id": "ClinicalImpression.note", "path": "ClinicalImpression.note", "short": "Comments made about the ClinicalImpression", "definition": "Berisi komentar tentang kesan atau impression, biasanya direkam setelah kesan itu sendiri dibuat, meskipun catatan tambahan oleh penulis asli juga dapat muncul dengan tipe data Annotation.", "comment": "Don't use this element for content that should more properly appear as one of the specific elements of the impression.", "min": 0, "max": "1", "base": { "path": "ClinicalImpression.note", "min": 0, "max": "*" }, "type": [ { "code": "Annotation" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children unless an empty Parameters resource", "expression": "hasValue() or (children().count() > id.count()) or $this is Parameters", "xpath": "@value|f:*|h:div|self::f:Parameters", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "Act" }, { "identity": "workflow", "map": "Event.note" } ] } ] }, "differential": { "element": [ { "id": "ClinicalImpression.identifier", "path": "ClinicalImpression.identifier", "definition": "Berisi satu atau lebih daftar data ID internal faskes untuk data clinical impression yang setiap datanya direpresentasikan dengan tipe data Identifier.", "max": "1" }, { "id": "ClinicalImpression.identifier.use", "path": "ClinicalImpression.identifier.use", "definition": "Berisi data dengan tipe data code, yang nilainya mengacu pada data terminologi IdentifierUse." }, { "id": "ClinicalImpression.identifier.system", "path": "ClinicalImpression.identifier.system", "definition": "Berisi data yang nilainya memiliki format: http://sys-ids.kemkes.go.id/clinicalimpression/{{organization-ihs-number}}" }, { "id": "ClinicalImpression.identifier.value", "path": "ClinicalImpression.identifier.value", "definition": "Berisi kode atau ID lokal yang disimpan di sistem internal masing-masing organisasi." }, { "id": "ClinicalImpression.status", "path": "ClinicalImpression.status", "definition": "Digunakan untuk mengidentifikasi status alur kerja penilaian atau asesmen yang setiap datanya direpresentasikan dengan tipe data code, yang nilainya mengacu pada data terminologi EventStatus." }, { "id": "ClinicalImpression.statusReason", "path": "ClinicalImpression.statusReason", "definition": "Berisi informasi terkait alasan status dari asesmen dengan tipe data CodeableConcept." }, { "id": "ClinicalImpression.statusReason.coding", "path": "ClinicalImpression.statusReason.coding", "definition": "Berisi data kode alasan status dari asesmen dengan tipe data Coding." }, { "id": "ClinicalImpression.statusReason.text", "path": "ClinicalImpression.statusReason.text", "definition": "Berisi alasan status asesmen dengan tipe data text." }, { "id": "ClinicalImpression.code", "path": "ClinicalImpression.code", "definition": "Berisi informasi mengenai kategori dari asesmen klinis yang dilakukan dengan tipe data CodeableConcept." }, { "id": "ClinicalImpression.code.coding", "path": "ClinicalImpression.code.coding", "definition": "Berisi data kode kategori dari asesmen klinis yang sedang dilakukan dengan tipe data Coding." }, { "id": "ClinicalImpression.code.text", "path": "ClinicalImpression.code.text", "definition": "Berisi informasi mengenai kategori dari asesmen klinis yang dilakukan dengan tipe data text." }, { "id": "ClinicalImpression.description", "path": "ClinicalImpression.description", "definition": "Berisi Rangkuman konteks dan atau penyebab dilakukannya asesmen, kenapa dan di mana dilakukan, dan kondisi pasien apa yang mendasari dilakukannya suatu asesmen dengan tipe data string." }, { "id": "ClinicalImpression.subject", "path": "ClinicalImpression.subject", "definition": "Berkaitan dengan subjek dari ClinicalImpression itu sendiri yang pada bagian ini berisi data dengan tipe data Reference yang direferensikan ke data yang tersimpan di resource Patient | Group." }, { "id": "ClinicalImpression.subject.reference", "path": "ClinicalImpression.subject.reference", "definition": "Berisi subjek dari ClinicalImpression, yang diisikan dengan ID Patient." }, { "id": "ClinicalImpression.subject.display", "path": "ClinicalImpression.subject.display", "definition": "Berisi Nama pasien dalam bentuk free text." }, { "id": "ClinicalImpression.encounter", "path": "ClinicalImpression.encounter", "definition": "Berisi informasi terkait kunjungan di mana asesmen dilakukan dengan tipe data Reference, yang direferensikan ke data yang tersimpan di resource Encounter.", "min": 1 }, { "id": "ClinicalImpression.effective[x]", "path": "ClinicalImpression.effective[x]", "slicing": { "discriminator": [ { "type": "type", "path": "$this" } ], "ordered": false, "rules": "open" }, "definition": "Berisi informasi mengenai waktu dilakukannya asesmen." }, { "id": "ClinicalImpression.effective[x]:effectiveDateTime", "path": "ClinicalImpression.effective[x]", "sliceName": "effectiveDateTime", "definition": "Berisi data mengenai kapan asesmen dilakukan dengan tipe data dateTime, dengan format yang diperbolehkan YYYY, YYYY-MM, YYYY-MM-DD atau YYYY-MM-DDThh:mm:ss+zz:zz.", "min": 0, "max": "1", "type": [ { "code": "dateTime" } ] }, { "id": "ClinicalImpression.effective[x]:effectivePeriod", "path": "ClinicalImpression.effective[x]", "sliceName": "effectivePeriod", "definition": "Berisi data waktu dari asesmen dimulai sampai selesai (arrived to finished) dengan tipe data Period.", "min": 0, "max": "1", "type": [ { "code": "Period" } ] }, { "id": "ClinicalImpression.effective[x]:effectivePeriod.start", "path": "ClinicalImpression.effective[x].start", "definition": "Diisi dengan waktu mulai, sama dengan waktu asesmen pasien dalam format YYYY-MM-DD." }, { "id": "ClinicalImpression.effective[x]:effectivePeriod.end", "path": "ClinicalImpression.effective[x].end", "definition": "Diisi dengan waktu selesai, sama dengan waktu selesai asesmen pasien dalam format YYYY-MM-DD." }, { "id": "ClinicalImpression.date", "path": "ClinicalImpression.date", "definition": "Merupakan waktu data asesmen dicatat atau didokumentasikan. Pada bagian ini berisi data dengan tipe data dateTime, dengan format yang diperbolehkan YYYY, YYYY-MM, YYYY-MM-DD atau YYYY-MM-DDThh:mm:ss+zz:zz." }, { "id": "ClinicalImpression.assessor", "path": "ClinicalImpression.assessor", "definition": "Berisi informasi mengenai klinisi yang melakukan asesmen. Pada bagian ini berisi data dengan tipe data Reference yang direferensikan ke data yang tersimpan di resource Practitioner dan PractitionerRole." }, { "id": "ClinicalImpression.previous", "path": "ClinicalImpression.previous", "definition": "Berisi referensi terhadap asesmen sebelumnya. Pada bagian ini berisi data dengan tipe data Reference yang direferensikan ke data yang tersimpan di resource ClinicalImpression." }, { "id": "ClinicalImpression.problem", "path": "ClinicalImpression.problem", "definition": "Berisi daftar kondisi atau masalah yang relevan pada pasien. Pada bagian ini berisi data dengan tipe data Reference yang direferensikan ke data yang tersimpan di resource Condition dan AllergyIntolerance.", "max": "1" }, { "id": "ClinicalImpression.investigation", "path": "ClinicalImpression.investigation", "definition": "Berisi satu atau lebih rangkaian pemeriksaan (tanda, gejala, dll.). Pengelompokan investigasi yang sebenarnya sangat bervariasi tergantung pada jenis dan konteks penilaian. Investigasi ini dapat mencakup data yang dihasilkan selama proses penilaian, atau data yang dihasilkan dan dicatat sebelumnya yang berkaitan dengan hasil dengan tipe data BackboneElement.", "max": "1" }, { "id": "ClinicalImpression.investigation.code", "path": "ClinicalImpression.investigation.code", "definition": "Berisi kelompok nama atau kode investigasi yang dilakukan untuk melakukan asesmen. Berkaitan dengan tanda, gejala, klinis, diagnostik namun tidak terbatasi dan kelompok lain seperti riwayat paparan/keluarga/perjalanan/nutrisi dapat digunakan dengan tipe data CodeableConcept." }, { "id": "ClinicalImpression.investigation.item", "path": "ClinicalImpression.investigation.item", "definition": "Berisi catatan terhadap investigasi atau tindakan yang dilakukan untuk asesmen ini. Pada bagian ini berisi data dengan tipe data Reference yang direferensikan ke data yang tersimpan di resource Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media.", "max": "1" }, { "id": "ClinicalImpression.protocol", "path": "ClinicalImpression.protocol", "definition": "Berisi referensi terhadap protokol klinis tertentu yang diterbitkan yang diikuti selama asesmen ini, dan/atau yang memberikan bukti untuk mendukung diagnosis dengan tipe data uri.", "max": "1" }, { "id": "ClinicalImpression.summary", "path": "ClinicalImpression.summary", "definition": "Berisi ringkasan teks dari investigasi dan diagnosis dengan tipe data string." }, { "id": "ClinicalImpression.finding", "path": "ClinicalImpression.finding", "definition": "Berisi data temuan atau diagnosis spesifik yang dianggap mungkin atau relevan dengan pengobatan yang sedang berlangsung dengan tipe data BackboneElement.", "max": "1" }, { "id": "ClinicalImpression.finding.itemCodeableConcept", "path": "ClinicalImpression.finding.itemCodeableConcept", "definition": "Berisi teks atau kode spesifik terkait temuan atau diagnosis yang relevan terhadap perawatan yang dilakukan dengan tipe data CodeableConcept." }, { "id": "ClinicalImpression.finding.itemCodeableConcept.coding", "path": "ClinicalImpression.finding.itemCodeableConcept.coding", "definition": "Berisi data kode spesifik terkait temuan atau diagnosis yang relevan dengan tipe data Coding yang nilainya mengacu pada data terminologi ICD-10 code versi 2010." }, { "id": "ClinicalImpression.finding.itemCodeableConcept.text", "path": "ClinicalImpression.finding.itemCodeableConcept.text", "definition": "Berisi teks terkait temuan atau diagnosis yang relevan terhadap perawatan yang dilakukan dengan tipe data text." }, { "id": "ClinicalImpression.finding.itemReference", "path": "ClinicalImpression.finding.itemReference", "definition": "Berisi informasi referensi spesifik terkait temuan atau diagnosis yang relevan terhadap perawatan yang dilakukan. Pada bagian ini berisi data dengan tipe data Reference yang direferensikan ke data yang tersimpan di resource Condition | Observation | Media." }, { "id": "ClinicalImpression.finding.basis", "path": "ClinicalImpression.finding.basis", "definition": "Berisi informasi mengenai investigasi yang mendukung temuan atau diagnosis dalam bentuk teks dengan tipe data string." }, { "id": "ClinicalImpression.prognosisCodeableConcept", "path": "ClinicalImpression.prognosisCodeableConcept", "definition": "Berisi informasi perkiraan kemungkinan outcome atau luaran dari kondisi pasien dengan tipe data CodeableConcept.", "min": 1, "max": "1" }, { "id": "ClinicalImpression.prognosisCodeableConcept.coding", "path": "ClinicalImpression.prognosisCodeableConcept.coding", "definition": "Berisi data kode outcome atau luaran kondisi pasien dengan tipe data Coding." }, { "id": "ClinicalImpression.prognosisCodeableConcept.text", "path": "ClinicalImpression.prognosisCodeableConcept.text", "definition": "Berisi informasi perkiraan kemungkinan outcome atau luaran dari kondisi pasien dengan tipe data text." }, { "id": "ClinicalImpression.prognosisReference", "path": "ClinicalImpression.prognosisReference", "definition": "Berisi informasi mengenai referensi kemungkinan outcome atau luaran pasien dengan tipe data Reference yang direferensikan ke data yang tersimpan di resource RiskAssessment.", "max": "1" }, { "id": "ClinicalImpression.supportingInfo", "path": "ClinicalImpression.supportingInfo", "definition": "Berisi informasi mengenai referensi data yang mendukung pada bagian ClinicalImpression ini. Pada bagian ini berisi data dengan tipe data Reference yang direferensikan ke data yang tersimpan di semua resource FHIR yang tersedia.", "max": "1" }, { "id": "ClinicalImpression.note", "path": "ClinicalImpression.note", "definition": "Berisi komentar tentang kesan atau impression, biasanya direkam setelah kesan itu sendiri dibuat, meskipun catatan tambahan oleh penulis asli juga dapat muncul dengan tipe data Annotation.", "max": "1" } ] } }