{ "resourceType": "StructureDefinition", "id": "OperationNoteModel", "text": { "status": "extensions", "div": "

Generated Narrative: StructureDefinition OperationNoteModel

\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
NameFlagsCard.TypeDescription & Constraints\"doco\"
\".\"\".\" OperationNoteModel 0..*Base手術紀錄(OperationNote)之資料模型
Instances of this logical model are not marked to be the target of a Reference
\".\"\".\"\".\" organization 1..1BackboneElement醫事機構
\".\"\".\"\".\"\".\" identifier 1..1Identifier醫事機構代碼
\".\"\".\"\".\"\".\" name 1..1string醫事機構名稱
\".\"\".\"\".\" patient 1..1BackboneElement病人的基本資料
\".\"\".\"\".\"\".\" identifier 1..1Identifier身分證字號
\".\"\".\"\".\"\".\" patientNo 1..1Identifier病歷號碼
\".\"\".\"\".\"\".\" name 1..*HumanName姓名
\".\"\".\"\".\"\".\" gender 1..1CodeableConcept性別
\".\"\".\"\".\"\".\" birthDate 1..1dateTime出生日期
\".\"\".\"\".\"\".\" bloodtype 0..1CodeableConcept血型
\".\"\".\"\".\" operation 1..1BackboneElement手術資料
\".\"\".\"\".\"\".\" operationDateTime 1..1dateTime手術日期時間
\".\"\".\"\".\"\".\" preoperativeDiagnosis 1..*CodeableConcept手術前診斷
\".\"\".\"\".\"\".\" postoperativeDiagnosis[x] 0..*手術後診斷
\".\"\".\"\".\"\".\"\".\" postoperativeDiagnosisNarrativeNarrative
\".\"\".\"\".\"\".\"\".\" postoperativeDiagnosisCodeableConceptCodeableConcept
\".\"\".\"\".\"\".\" operationCode 1..1CodeableConcept手術代碼
\".\"\".\"\".\"\".\" bodyPart 0..*CodeableConcept手術部位
\".\"\".\"\".\"\".\" indication 1..1string手術目的
\".\"\".\"\".\"\".\" bloodLoss[x] 0..1失血量
\".\"\".\"\".\"\".\"\".\" bloodLossNarrativeNarrative
\".\"\".\"\".\"\".\"\".\" bloodLossDecimaldecimal
\".\"\".\"\".\"\".\" anesthesiaMode[x] 0..1麻醉模式
\".\"\".\"\".\"\".\"\".\" anesthesiaModeNarrativeNarrative
\".\"\".\"\".\"\".\"\".\" anesthesiaModeCodeableConceptCodeableConcept
\".\"\".\"\".\"\".\" anesthesiologist 0..*HumanName麻醉醫師
\".\"\".\"\".\"\".\" operativeFinding 1..*markdown手術發現
\".\"\".\"\".\"\".\" operationProcedure 1..*markdown手術過程紀錄
\".\"\".\"\".\"\".\" device 0..*CodeableConcept手術特材
\".\"\".\"\".\"\".\" surgeon 0..*HumanName手術醫師
\".\"\".\"\".\"\".\" surgicalImage 0..*url手術圖像

\"doco\" Documentation for this format
" }, "url": "https://imri.cgh.org.tw/imri/StructureDefinition/OperationNoteModel", "version": "0.1.0", "name": "OperationNoteModel", "title": "手術紀錄(OperationNote)之資料模型", "status": "active", "date": "2024-11-26T14:24:42+00:00", "publisher": "國泰金控", "contact": [ { "name": "國泰金控", "telecom": [ { "system": "url", "value": "https://www.cathayholdings.com/holdings/" } ] } ], "description": "手術紀錄(OperationNote)之資料模型", "fhirVersion": "4.0.1", "mapping": [ { "identity": "OperationNote", "uri": "https://imri.cgh.org.tw/imri/", "name": "IMRI" } ], "kind": "logical", "abstract": false, "type": "https://imri.cgh.org.tw/imri/StructureDefinition/OperationNoteModel", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Base", "derivation": "specialization", "differential": { "element": [ { "id": "OperationNoteModel", "path": "OperationNoteModel", "short": "手術紀錄(OperationNote)之資料模型", "definition": "手術紀錄(OperationNote)之資料模型", "mapping": [ { "identity": "OperationNote", "map": "BundleOperationNoteIMRI" } ] }, { "id": "OperationNoteModel.organization", "path": "OperationNoteModel.organization", "short": "醫事機構", "definition": "醫事機構", "min": 1, "max": "1", "type": [ { "code": "BackboneElement" } ] }, { "id": "OperationNoteModel.organization.identifier", "path": "OperationNoteModel.organization.identifier", "short": "醫事機構代碼", "definition": "醫事機構代碼", "min": 1, "max": "1", "type": [ { "code": "Identifier" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:OrganizationHospIMRI.identifier" } ] }, { "id": "OperationNoteModel.organization.name", "path": "OperationNoteModel.organization.name", "short": "醫事機構名稱", "definition": "醫事機構名稱", "min": 1, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:OrganizationHospIMRI.name" } ] }, { "id": "OperationNoteModel.patient", "path": "OperationNoteModel.patient", "short": "病人的基本資料", "definition": "病人的基本資料", "min": 1, "max": "1", "type": [ { "code": "BackboneElement" } ] }, { "id": "OperationNoteModel.patient.identifier", "path": "OperationNoteModel.patient.identifier", "short": "身分證字號", "definition": "身分證字號", "min": 1, "max": "1", "type": [ { "code": "Identifier" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:PatientIMRI.identifier:idCardNumber" } ] }, { "id": "OperationNoteModel.patient.patientNo", "path": "OperationNoteModel.patient.patientNo", "short": "病歷號碼", "definition": "病歷號碼", "min": 1, "max": "1", "type": [ { "code": "Identifier" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:PatientIMRI.identifier:medicalRecord" } ] }, { "id": "OperationNoteModel.patient.name", "path": "OperationNoteModel.patient.name", "short": "姓名", "definition": "病人之合法姓名。", "min": 1, "max": "*", "type": [ { "code": "HumanName" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:PatientIMRI.name" } ] }, { "id": "OperationNoteModel.patient.gender", "path": "OperationNoteModel.patient.gender", "short": "性別", "definition": "性別", "min": 1, "max": "1", "type": [ { "code": "CodeableConcept" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:PatientIMRI.gender" } ] }, { "id": "OperationNoteModel.patient.birthDate", "path": "OperationNoteModel.patient.birthDate", "short": "出生日期", "definition": "病人的生日，如果有完整或部分的生日日期則必須提供，若無完整或部分的生日日期則以空字串''表示之。", "min": 1, "max": "1", "type": [ { "code": "dateTime" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:PatientIMRI.birthDate" } ] }, { "id": "OperationNoteModel.patient.bloodtype", "path": "OperationNoteModel.patient.bloodtype", "short": "血型", "definition": "血型", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:ObservationBloodTypeIMRI.valueCodeableConcept" } ] }, { "id": "OperationNoteModel.operation", "path": "OperationNoteModel.operation", "short": "手術資料", "definition": "手術資料", "min": 1, "max": "1", "type": [ { "code": "BackboneElement" } ] }, { "id": "OperationNoteModel.operation.operationDateTime", "path": "OperationNoteModel.operation.operationDateTime", "short": "手術日期時間", "definition": "手術日期時間", "min": 1, "max": "1", "type": [ { "code": "dateTime" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:ProcedureOperationIMRI.performedDateTime" } ] }, { "id": "OperationNoteModel.operation.preoperativeDiagnosis", "path": "OperationNoteModel.operation.preoperativeDiagnosis", "short": "手術前診斷", "definition": "手術前診斷", "min": 1, "max": "*", "type": [ { "code": "CodeableConcept" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:ProcedureOperationIMRI.reasonReference.Reference(TWCoreCondition).code.coding.code" } ] }, { "id": "OperationNoteModel.operation.postoperativeDiagnosis[x]", "path": "OperationNoteModel.operation.postoperativeDiagnosis[x]", "short": "手術後診斷", "definition": "手術後診斷", "min": 0, "max": "*", "type": [ { "code": "Narrative" }, { "code": "CodeableConcept" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:CompositionOperationNoteIMRI.section:OperationNote.section:postoperativeDiagnosis.text 或 entry:TWCoreCondition.code.coding.code" } ] }, { "id": "OperationNoteModel.operation.operationCode", "path": "OperationNoteModel.operation.operationCode", "short": "手術代碼", "definition": "手術代碼", "min": 1, "max": "1", "type": [ { "code": "CodeableConcept" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:ProcedureOperationIMRI.code.coding.code" } ] }, { "id": "OperationNoteModel.operation.bodyPart", "path": "OperationNoteModel.operation.bodyPart", "short": "手術部位", "definition": "手術部位", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:ProcedureOperationIMRI.bodySite" } ] }, { "id": "OperationNoteModel.operation.indication", "path": "OperationNoteModel.operation.indication", "short": "手術目的", "definition": "手術目的", "min": 1, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:ProcedureOperationIMRI.code.coding.display" } ] }, { "id": "OperationNoteModel.operation.bloodLoss[x]", "path": "OperationNoteModel.operation.bloodLoss[x]", "short": "失血量", "definition": "失血量", "min": 0, "max": "1", "type": [ { "code": "Narrative" }, { "code": "decimal" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:CompositionOperationNoteIMRI.section:OperationNote.section:bloodLoss.text 或 entry:ObservationBloodLossIMRI.valueQuantity.value" } ] }, { "id": "OperationNoteModel.operation.anesthesiaMode[x]", "path": "OperationNoteModel.operation.anesthesiaMode[x]", "short": "麻醉模式", "definition": "麻醉模式", "min": 0, "max": "1", "type": [ { "code": "Narrative" }, { "code": "CodeableConcept" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:CompositionOperationNoteIMRI.section:OperationNote.section:anesthesiaMode.text 或 entry:ProcedureAnesthesiaModeIMRI.code" } ] }, { "id": "OperationNoteModel.operation.anesthesiologist", "path": "OperationNoteModel.operation.anesthesiologist", "short": "麻醉醫師", "definition": "麻醉醫師", "min": 0, "max": "*", "type": [ { "code": "HumanName" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:ProcedureAnesthesiaModeIMRI.performer.actor.Reference(PractitionerRoleIMRI).where(code = '88189002').practitioner.Reference(PractitionerIMRI).name" } ] }, { "id": "OperationNoteModel.operation.operativeFinding", "path": "OperationNoteModel.operation.operativeFinding", "short": "手術發現", "definition": "手術發現", "min": 1, "max": "*", "type": [ { "code": "markdown" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:ProcedureOperationIMRI.note[0].text" } ] }, { "id": "OperationNoteModel.operation.operationProcedure", "path": "OperationNoteModel.operation.operationProcedure", "short": "手術過程紀錄", "definition": "手術過程紀錄", "min": 1, "max": "*", "type": [ { "code": "markdown" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:ProcedureOperationIMRI.note[1].text" } ] }, { "id": "OperationNoteModel.operation.device", "path": "OperationNoteModel.operation.device", "short": "手術特材", "definition": "手術特材", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:ProcedureOperationIMRI.usedCode" } ] }, { "id": "OperationNoteModel.operation.surgeon", "path": "OperationNoteModel.operation.surgeon", "short": "手術醫師", "definition": "手術醫師", "min": 0, "max": "*", "type": [ { "code": "HumanName" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:ProcedureOperationIMRI.performer.actor.Reference(PractitionerRoleIMRI).where(code = '304292004').practitioner.Reference(PractitionerIMRI).name" } ] }, { "id": "OperationNoteModel.operation.surgicalImage", "path": "OperationNoteModel.operation.surgicalImage", "short": "手術圖像", "definition": "手術圖像", "min": 0, "max": "*", "type": [ { "code": "url" } ], "mapping": [ { "identity": "OperationNote", "map": "entry:ProcedureOperationIMRI.report.Reference(TWCoreDocumentReference).content.attachment.url" } ] } ] } }