Generated Narrative: StructureDefinition composition-dischargesummary-imri

Name Flags Card. Type Description & Constraints doco
. . Composition TWCoreComposition
. . . status 1 .. 1 code registered | partial | preliminary | final | amended | corrected +
Required Pattern: final
. . . type 1 .. 1 CodeableConceptTW Composition的種類（如果可能請使用LOINC）
Required Pattern: At least the following
. . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18842-5
. . . . . display 1..1 string Representation defined by the system
Fixed Value: Discharge summary
. . . subject 1..1 Reference(Patient IMRI) Composition是關於誰和/或什麼
. . . encounter S 1..1 Reference(Encounter IMRI) Composition的情境
. . . author 1 .. * Reference(Organization Hospital Department IMRI | Practitioner IMRI) 誰和/或什麼創建了這個Composition
. . . title 1 .. 1 string 人類可讀的名稱/標題
Fixed Value: 出院病歷摘要
. . . attester
. . . . party 0 .. 1 Reference(Patient IMRI | RelatedPerson | Practitioner IMRI | PractitionerRole IMRI | Organization Hospital Department IMRI) 誰證明了此Composition
. . . custodian 0 .. 1 Reference(Organization Hospital Department IMRI) 維護Composition的機構
. . . Slices for section 5 .. * BackboneElement Composition被分成一個或數個小節
Slice: Unordered, Closed by value:code
. . . . section:Impression S C 0..* BackboneElement Composition被分成一個或數個小節
imri-2: Composition.section.text or Composition.section.entry SHALL be present
. . . . . title 0 .. 1 string 小節標籤(例如：目錄ToC)
Fixed Value: 住院臆斷
. . . . . code 1..1 CodeableConceptTW 小節分類(建議)
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46241-6
. . . . . . . display 1..1 string Representation defined by the system
Fixed Value: Hospital admission diagnosis Narrative - Reported
. . . . . entry 0 .. * Reference(ObservationImpression IMRI) 提供一個連結用於參照或查看支持此小節內容的資料
. . . . section:DischargeDiagnosis S 1..* BackboneElement Composition被分成一個或數個小節
. . . . . title 0 .. 1 string 小節標籤(例如：目錄ToC)
Fixed Value: 出院診斷
. . . . . code 1..1 CodeableConceptTW 小節分類(建議)
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11535-2
. . . . . . . display 1..1 string Representation defined by the system
Fixed Value: Hospital discharge Dx Narrative
. . . . . entry 1..* Reference(ConditionDischargeDiagnosis IMRI) 提供一個連結用於參照或查看支持此小節內容的資料
. . . . section:CancerStaging S 0..1 BackboneElement Composition被分成一個或數個小節
. . . . . title 0 .. 1 string 小節標籤(例如：目錄ToC)
Fixed Value: 癌症期別
. . . . . code 1..1 CodeableConceptTW 小節分類(建議)
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 22037-6
. . . . . . . display 1..1 string Representation defined by the system
Fixed Value: Staging Cancer Narrative
. . . . . entry 0 .. * Reference(ObservationCancerStaging IMRI) 提供一個連結用於參照或查看支持此小節內容的資料
. . . . section:ChiefComplaint S C 1..1 BackboneElement Composition被分成一個或數個小節
imri-2: Composition.section.text or Composition.section.entry SHALL be present
. . . . . title 0 .. 1 string 小節標籤(例如：目錄ToC)
Fixed Value: 主訴
. . . . . code 1..1 CodeableConceptTW 小節分類(建議)
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10154-3
. . . . . . . display 1..1 string Representation defined by the system
Fixed Value: Chief complaint Narrative - Reported
. . . . . entry 0 .. * Reference(ConditionChiefComplaint IMRI) 提供一個連結用於參照或查看支持此小節內容的資料
. . . . section:PresentIllness S C 0..* BackboneElement Composition被分成一個或數個小節
imri-2: Composition.section.text or Composition.section.entry SHALL be present
. . . . . title 0 .. 1 string 小節標籤(例如：目錄ToC)
Fixed Value: 病史
. . . . . code 1..1 CodeableConceptTW 小節分類(建議)
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10164-2
. . . . . . . display 1..1 string Representation defined by the system
Fixed Value: History of Present illness Narrative
. . . . . entry 0 .. * Reference(ConditionPresentIllness IMRI) 提供一個連結用於參照或查看支持此小節內容的資料
. . . . section:PhysicalExamination S 0..* BackboneElement Composition被分成一個或數個小節
. . . . . title 0 .. 1 string 小節標籤(例如：目錄ToC)
Fixed Value: 理學檢查發現
. . . . . code 1..1 CodeableConceptTW 小節分類(建議)
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29545-1
. . . . . . . display 1..1 string Representation defined by the system
Fixed Value: Physical findings Narrative
. . . . . entry 0 .. * Reference(ObservationPhysicalExamination IMRI) 提供一個連結用於參照或查看支持此小節內容的資料
. . . . section:LaboratoryData S 0..* BackboneElement Composition被分成一個或數個小節
. . . . . title 0 .. 1 string 小節標籤(例如：目錄ToC)
Fixed Value: 檢驗與特殊檢查
. . . . . code 1..1 CodeableConceptTW 小節分類(建議)
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 30954-2
. . . . . . . display 1..1 string Representation defined by the system
Fixed Value: Relevant diagnostic tests/laboratory data Narrative
. . . . . entry 0 .. * Reference(ObservationLaboratory IMRI) 提供一個連結用於參照或查看支持此小節內容的資料
. . . . section:ImagingStudy S 0..* BackboneElement Composition被分成一個或數個小節
. . . . . title 0 .. 1 string 小節標籤(例如：目錄ToC)
Fixed Value: 醫療影像檢查
. . . . . code 1..1 CodeableConceptTW 小節分類(建議)
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18748-4
. . . . . . . display 1..1 string Representation defined by the system
Fixed Value: Diagnostic imaging study
. . . . . entry 0 .. * Reference(ImagingStudy IMRI) 提供一個連結用於參照或查看支持此小節內容的資料
. . . . section:PathologyReport S 0..* BackboneElement Composition被分成一個或數個小節
. . . . . title 0 .. 1 string 小節標籤(例如：目錄ToC)
Fixed Value: 病理報告
. . . . . code 1..1 CodeableConceptTW 小節分類(建議)
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 22034-3
. . . . . . . display 1..1 string Representation defined by the system
Fixed Value: Pathology report Cancer Narrative
. . . . . entry 0 .. * Reference(ObservationPathologyReport IMRI) 提供一個連結用於參照或查看支持此小節內容的資料
. . . . section:SurgicalMethod S 1..* BackboneElement Composition被分成一個或數個小節
. . . . . title 0 .. 1 string 小節標籤(例如：目錄ToC)
Fixed Value: 手術日期及方法
. . . . . code 1..1 CodeableConceptTW 小節分類(建議)
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 8724-7
. . . . . . . display 1..1 string Representation defined by the system
Fixed Value: Surgical operation note description Narrative
. . . . . entry 1..* Reference(Procedure IMRI) 提供一個連結用於參照或查看支持此小節內容的資料
. . . . section:HospitalCourse S C 1..1 BackboneElement Composition被分成一個或數個小節
imri-2: Composition.section.text or Composition.section.entry SHALL be present
. . . . . title 0 .. 1 string 小節標籤(例如：目錄ToC)
Fixed Value: 住院治療經過
. . . . . code 1..1 CodeableConceptTW 小節分類(建議)
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 8648-8
. . . . . . . display 1..1 string Representation defined by the system
Fixed Value: Hospital course Narrative
. . . . . entry 0 .. * Reference(ProcedureHospitalCourse IMRI | Location IMRI) 提供一個連結用於參照或查看支持此小節內容的資料
. . . . section:ComorbiditesAndOrComlications S 0..* BackboneElement Composition被分成一個或數個小節
. . . . . title 0 .. 1 string 小節標籤(例如：目錄ToC)
Fixed Value: 合併症與併發症
. . . . . code 1..1 CodeableConceptTW 小節分類(建議)
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 55109-3
. . . . . . . display 1..1 string Representation defined by the system
Fixed Value: Complications Document
. . . . . entry 0 .. * Reference(ConditionComorbiditiesandComplications IMRI) 提供一個連結用於參照或查看支持此小節內容的資料
. . . . section:InstructionsOnDischarge S 1..1 BackboneElement Composition被分成一個或數個小節
. . . . . title 0 .. 1 string 小節標籤(例如：目錄ToC)
Fixed Value: 出院指示
. . . . . code 1..1 CodeableConceptTW 小節分類(建議)
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 8653-8
. . . . . . . display 1..1 string Representation defined by the system
Fixed Value: Hospital Discharge instructions
. . . . . entry 0 .. * Reference(CarePlan IMRI | MedicationRequest IMRI) 提供一個連結用於參照或查看支持此小節內容的資料

doco Documentation for this format
<status value="active" /> <date value="2024-11-26T22:24:42+08:00" /> <publisher value="國泰金控" /> <contact> <name value="國泰金控" /> <telecom> <system value="url" /> <value value="https://www.cathayholdings.com/holdings/" /> </telecom> </contact> <description value="此Profile說明本IG如何進一步定義臺灣核心-臨床文件架構（TW Core Composition) Profile以呈現出院病摘的報告文件。" /> <fhirVersion value="4.0.1" /> <mapping> <identity value="workflow" /> <uri value="http://hl7.org/fhir/workflow" /> <name value="Workflow Pattern" /> </mapping> <mapping> <identity value="rim" /> <uri value="http://hl7.org/v3" /> <name value="RIM Mapping" /> </mapping> <mapping> <identity value="cda" /> <uri value="http://hl7.org/v3/cda" /> <name value="CDA (R2)" /> </mapping> <mapping> <identity value="fhirdocumentreference" /> <uri value="http://hl7.org/fhir/documentreference" /> <name value="FHIR DocumentReference" /> </mapping> <mapping> <identity value="w5" /> <uri value="http://hl7.org/fhir/fivews" /> <name value="FiveWs Pattern Mapping" /> </mapping> <kind value="resource" /> <abstract value="false" /> <type value="Composition" /> <baseDefinition value="https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Composition-twcore" /> <derivation value="constraint" /> <differential> <element id="Composition.status"> <path value="Composition.status" /> <patternCode value="final" /> </element> <element id="Composition.type"> <path value="Composition.type" /> <patternCodeableConcept> <coding> <system value="http://loinc.org" /> <code value="18842-5" /> <display value="Discharge summary" /> </coding> </patternCodeableConcept> </element> <element id="Composition.subject"> <path value="Composition.subject" /> <min value="1" /> <type> <code value="Reference" /> <targetProfile value="https://imri.cgh.org.tw/imri/StructureDefinition/patient-imri" /> </type> </element> <element id="Composition.encounter"> <path value="Composition.encounter" /> <min value="1" /> <type> <code value="Reference" /> <targetProfile value="https://imri.cgh.org.tw/imri/StructureDefinition/encounter-imri" /> </type> <mustSupport value="true" /> </element> <element id="Composition.author"> <path value="Composition.author" /> <type> <code value="Reference" /> <targetProfile value="https://imri.cgh.org.tw/imri/StructureDefinition/organization-hosp-imri" /> <targetProfile value="https://imri.cgh.org.tw/imri/StructureDefinition/practitioner-imri" /> </type> </element> <element id="Composition.title"> <path value="Composition.title" /> <fixedString value="出院病歷摘要" /> </element> <element id="Composition.attester.party"> <path value="Composition.attester.party" /> <type> <code value="Reference" /> <targetProfile value="https://imri.cgh.org.tw/imri/StructureDefinition/patient-imri" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/RelatedPerson" /> <targetProfile value="https://imri.cgh.org.tw/imri/StructureDefinition/practitioner-imri" /> <targetProfile value="https://imri.cgh.org.tw/imri/StructureDefinition/practitionerrole-imri" /> <targetProfile value="https://imri.cgh.org.tw/imri/StructureDefinition/organization-hosp-imri" /> </type> </element> <element id="Composition.custodian"> <path value="Composition.custodian" /> <type> <code value="Reference" /> <targetProfile value="https://imri.cgh.org.tw/imri/StructureDefinition/organization-hosp-imri" /> </type> </element> <element id="Composition.section"> <path value="Composition.section" /> <slicing> <discriminator> <type value="value" /> <path value="code" /> </discriminator> <rules value="closed" /> </slicing> <min value="5" /> </element> <element id="Composition.section:Impression"> <path value="Composition.section" /> <sliceName value="Impression" /> <min value="0" /> <max value="*" /> <condition value="imri-2" /> <constraint> <key value="imri-2" /> <severity value="error" /> <human value="Composition.section.text or Composition.section.entry SHALL be present" /> <expression value="text.exists() or entry.exists()" /> <source value="https://imri.cgh.org.tw/imri/StructureDefinition/composition-dischargesummary-imri" /> </constraint> <mustSupport value="true" /> </element> <element id="Composition.section:Impression.title"> <path value="Composition.section.title" /> <fixedString value="住院臆斷" /> </element> <element id="Composition.section:Impression.code"> <path value="Composition.section.code" /> <min value="1" /> <patternCodeableConcept> <coding> <system value="http://loinc.org" /> <code value="46241-6" /> <display value="Hospital admission diagnosis Narrative - Reported" /> </coding> </patternCodeableConcept> </element> <element id="Composition.section:Impression.entry"> <path value="Composition.section.entry" /> <type> <code value="Reference" /> <targetProfile value="https://imri.cgh.org.tw/imri/StructureDefinition/observation-impression-imri" /> </type> </element> <element id="Composition.section:DischargeDiagnosis"> <path value="Composition.section" /> <sliceName value="DischargeDiagnosis" /> <min value="1" /> <max value="*" /> <mustSupport value="true" /> </element> <element id="Composition.section:DischargeDiagnosis.title"> <path value="Composition.section.title" /> <fixedString value="出院診斷" /> </element> <element id="Composition.section:DischargeDiagnosis.code"> <path value="Composition.section.code" /> <min value="1" /> <patternCodeableConcept> <coding> <system value="http://loinc.org" /> <code value="11535-2" /> <display value="Hospital discharge Dx Narrative" /> </coding> </patternCodeableConcept> </element> <element id="Composition.section:DischargeDiagnosis.entry"> <path value="Composition.section.entry" /> <min value="1" /> <type> <code value="Reference" /> <targetProfile value="https://imri.cgh.org.tw/imri/StructureDefinition/conditiondischargediagnosis-imri" /> </type> </element> <element id="Composition.section:CancerStaging"> <path value="Composition.section" /> <sliceName value="CancerStaging" /> <min value="0" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="Composition.section:CancerStaging.title"> <path value="Composition.section.title" /> <fixedString value="癌症期別" /> </element> <element id="Composition.section:CancerStaging.code"> <path value="Composition.section.code" /> <min value="1" /> <patternCodeableConcept> <coding> <system value="http://loinc.org" /> <code value="22037-6" /> <display value="Staging Cancer Narrative" /> </coding> </patternCodeableConcept> </element> <element id="Composition.section:CancerStaging.entry"> <path value="Composition.section.entry" /> <type> <code value="Reference" /> <targetProfile value="https://imri.cgh.org.tw/imri/StructureDefinition/observation-cancerstaging-imri" /> </type> </element> <element id="Composition.section:ChiefComplaint"> <path value="Composition.section" /> <sliceName value="ChiefComplaint" /> <min value="1" /> <max value="1" /> <condition value="imri-2" /> <constraint> <key value="imri-2" /> <severity value="error" /> <human value="Composition.section.text or Composition.section.entry SHALL be present" /> <expression value="text.exists() or entry.exists()" /> <source value="https://imri.cgh.org.tw/imri/StructureDefinition/composition-dischargesummary-imri" /> </constraint> <mustSupport value="true" /> </element> <element id="Composition.section:ChiefComplaint.title"> <path value="Composition.section.title" /> <fixedString value="主訴" /> </element> <element id="Composition.section:ChiefComplaint.code"> <path value="Composition.section.code" /> <min value="1" /> <patternCodeableConcept> <coding> <system value="http://loinc.org" /> <code value="10154-3" /> <display value="Chief complaint Narrative - Reported" /> </coding> </patternCodeableConcept> </element> <element id="Composition.section:ChiefComplaint.entry"> <path value="Composition.section.entry" /> <type> <code value="Reference" /> <targetProfile value="https://imri.cgh.org.tw/imri/StructureDefinition/conditionchiefcomplaint-imri" /> </type> </element> <element id="Composition.section:PresentIllness"> <path value="Composition.section" /> <sliceName value="PresentIllness" /> <min value="0" /> <max value="*" /> <condition value="imri-2" /> <constraint> <key value="imri-2" /> <severity value="error" /> <human value="Composition.section.text or Composition.section.entry SHALL be present" /> <expression value="text.exists() or entry.exists()" /> <source value="https://imri.cgh.org.tw/imri/StructureDefinition/composition-dischargesummary-imri" /> </constraint> <mustSupport value="true" /> </element> <element id="Composition.section:PresentIllness.title"> <path value="Composition.section.title" /> <fixedString value="病史" /> </element> <element id="Composition.section:PresentIllness.code"> <path value="Composition.section.code" /> <min value="1" /> <patternCodeableConcept> <coding> <system value="http://loinc.org" /> <code value="10164-2" /> <display value="History of Present illness Narrative" /> </coding> </patternCodeableConcept> </element> <element id="Composition.section:PresentIllness.entry"> <path value="Composition.section.entry" /> <type> <code value="Reference" /> <targetProfile value="https://imri.cgh.org.tw/imri/StructureDefinition/conditionpresentillness-imri" /> </type> </element> <element id="Composition.section:PhysicalExamination"> <path value="Composition.section" /> <sliceName value="PhysicalExamination" /> <min value="0" /> <max value="*" /> <mustSupport value="true" /> </element> <element id="Composition.section:PhysicalExamination.title"> <path value="Composition.section.title" /> <fixedString value="理學檢查發現" /> </element> <element id="Composition.section:PhysicalExamination.code"> <path value="Composition.section.code" /> <min value="1" /> <patternCodeableConcept> <coding> <system value="http://loinc.org" /> <code value="29545-1" /> <display value="Physical findings Narrative" /> </coding> </patternCodeableConcept> </element> <element id="Composition.section:PhysicalExamination.entry"> <path value="Composition.section.entry" /> <type> <code value="Reference" /> <targetProfile value="https://imri.cgh.org.tw/imri/StructureDefinition/observation-physical-examination-imri" /> </type> </element> <element id="Composition.section:LaboratoryData"> <path value="Composition.section" /> <sliceName value="LaboratoryData" /> <min value="0" /> <max value="*" /> <mustSupport value="true" /> </element> <element id="Composition.section:LaboratoryData.title"> <path value="Composition.section.title" /> <fixedString value="檢驗與特殊檢查" /> </element> <element id="Composition.section:LaboratoryData.code"> <path value="Composition.section.code" /> <min value="1" /> <patternCodeableConcept> <coding> <system value="http://loinc.org" /> <code value="30954-2" /> <display value="Relevant diagnostic tests/laboratory data Narrative" /> </coding> </patternCodeableConcept> </element> <element id="Composition.section:LaboratoryData.entry"> <path value="Composition.section.entry" /> <type> <code value="Reference" /> <targetProfile value="https://imri.cgh.org.tw/imri/StructureDefinition/observation-laboratory-imri" /> </type> </element> <element id="Composition.section:ImagingStudy"> <path value="Composition.section" /> <sliceName value="ImagingStudy" /> <min value="0" /> <max value="*" /> <mustSupport value="true" /> </element> <element id="Composition.section:ImagingStudy.title"> <path value="Composition.section.title" /> <fixedString value="醫療影像檢查" /> </element> <element id="Composition.section:ImagingStudy.code"> <path value="Composition.section.code" /> <min value="1" /> <patternCodeableConcept> <coding> <system value="http://loinc.org" /> <code value="18748-4" /> <display value="Diagnostic imaging study" /> </coding> </patternCodeableConcept> </element> <element id="Composition.section:ImagingStudy.entry"> <path value="Composition.section.entry" /> <type> <code value="Reference" /> <targetProfile 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