Generated Narrative: StructureDefinition OperationNoteModel

Name Flags Card. Type Description & 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..1 BackboneElement 醫事機構
. . . . identifier 1..1 Identifier 醫事機構代碼
. . . . name 1..1 string 醫事機構名稱
. . . patient 1..1 BackboneElement 病人的基本資料
. . . . identifier 1..1 Identifier 身分證字號
. . . . patientNo 1..1 Identifier 病歷號碼
. . . . name 1..* HumanName 姓名
. . . . gender 1..1 CodeableConcept 性別
. . . . birthDate 1..1 dateTime 出生日期
. . . . bloodtype 0..1 CodeableConcept 血型
. . . operation 1..1 BackboneElement 手術資料
. . . . operationDateTime 1..1 dateTime 手術日期時間
. . . . preoperativeDiagnosis 1..* CodeableConcept 手術前診斷
. . . . postoperativeDiagnosis[x] 0..* 手術後診斷
. . . . . postoperativeDiagnosisNarrative Narrative
. . . . . postoperativeDiagnosisCodeableConcept CodeableConcept
. . . . operationCode 1..1 CodeableConcept 手術代碼
. . . . bodyPart 0..* CodeableConcept 手術部位
. . . . indication 1..1 string 手術目的
. . . . bloodLoss[x] 0..1 失血量
. . . . . bloodLossNarrative Narrative
. . . . . bloodLossDecimal decimal
. . . . anesthesiaMode[x] 0..1 麻醉模式
. . . . . anesthesiaModeNarrative Narrative
. . . . . anesthesiaModeCodeableConcept CodeableConcept
. . . . 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
<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="手術紀錄(OperationNote)之資料模型" /> <fhirVersion value="4.0.1" /> <mapping> <identity value="OperationNote" /> <uri value="https://imri.cgh.org.tw/imri/" /> <name value="IMRI" /> </mapping> <kind value="logical" /> <abstract value="false" /> <type value="https://imri.cgh.org.tw/imri/StructureDefinition/OperationNoteModel" /> <baseDefinition value="http://hl7.org/fhir/StructureDefinition/Base" /> <derivation value="specialization" /> <differential> <element id="OperationNoteModel"> <path value="OperationNoteModel" /> <short value="手術紀錄(OperationNote)之資料模型" /> <definition value="手術紀錄(OperationNote)之資料模型" /> <mapping> <identity value="OperationNote" /> <map value="BundleOperationNoteIMRI" /> </mapping> </element> <element id="OperationNoteModel.organization"> <path value="OperationNoteModel.organization" /> <short value="醫事機構" /> <definition value="醫事機構" /> <min value="1" /> <max value="1" /> <type> <code value="BackboneElement" /> </type> </element> <element id="OperationNoteModel.organization.identifier"> <path value="OperationNoteModel.organization.identifier" /> <short value="醫事機構代碼" /> <definition value="醫事機構代碼" /> <min value="1" /> <max value="1" /> <type> <code value="Identifier" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:OrganizationHospIMRI.identifier" /> </mapping> </element> <element id="OperationNoteModel.organization.name"> <path value="OperationNoteModel.organization.name" /> <short value="醫事機構名稱" /> <definition value="醫事機構名稱" /> <min value="1" /> <max value="1" /> <type> <code value="string" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:OrganizationHospIMRI.name" /> </mapping> </element> <element id="OperationNoteModel.patient"> <path value="OperationNoteModel.patient" /> <short value="病人的基本資料" /> <definition value="病人的基本資料" /> <min value="1" /> <max value="1" /> <type> <code value="BackboneElement" /> </type> </element> <element id="OperationNoteModel.patient.identifier"> <path value="OperationNoteModel.patient.identifier" /> <short value="身分證字號" /> <definition value="身分證字號" /> <min value="1" /> <max value="1" /> <type> <code value="Identifier" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:PatientIMRI.identifier:idCardNumber" /> </mapping> </element> <element id="OperationNoteModel.patient.patientNo"> <path value="OperationNoteModel.patient.patientNo" /> <short value="病歷號碼" /> <definition value="病歷號碼" /> <min value="1" /> <max value="1" /> <type> <code value="Identifier" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:PatientIMRI.identifier:medicalRecord" /> </mapping> </element> <element id="OperationNoteModel.patient.name"> <path value="OperationNoteModel.patient.name" /> <short value="姓名" /> <definition value="病人之合法姓名。" /> <min value="1" /> <max value="*" /> <type> <code value="HumanName" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:PatientIMRI.name" /> </mapping> </element> <element id="OperationNoteModel.patient.gender"> <path value="OperationNoteModel.patient.gender" /> <short value="性別" /> <definition value="性別" /> <min value="1" /> <max value="1" /> <type> <code value="CodeableConcept" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:PatientIMRI.gender" /> </mapping> </element> <element id="OperationNoteModel.patient.birthDate"> <path value="OperationNoteModel.patient.birthDate" /> <short value="出生日期" /> <definition value="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 value="1" /> <max value="1" /> <type> <code value="dateTime" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:PatientIMRI.birthDate" /> </mapping> </element> <element id="OperationNoteModel.patient.bloodtype"> <path value="OperationNoteModel.patient.bloodtype" /> <short value="血型" /> <definition value="血型" /> <min value="0" /> <max value="1" /> <type> <code value="CodeableConcept" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:ObservationBloodTypeIMRI.valueCodeableConcept" /> </mapping> </element> <element id="OperationNoteModel.operation"> <path value="OperationNoteModel.operation" /> <short value="手術資料" /> <definition value="手術資料" /> <min value="1" /> <max value="1" /> <type> <code value="BackboneElement" /> </type> </element> <element id="OperationNoteModel.operation.operationDateTime"> <path value="OperationNoteModel.operation.operationDateTime" /> <short value="手術日期時間" /> <definition value="手術日期時間" /> <min value="1" /> <max value="1" /> <type> <code value="dateTime" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:ProcedureOperationIMRI.performedDateTime" /> </mapping> </element> <element id="OperationNoteModel.operation.preoperativeDiagnosis"> <path value="OperationNoteModel.operation.preoperativeDiagnosis" /> <short value="手術前診斷" /> <definition value="手術前診斷" /> <min value="1" /> <max value="*" /> <type> <code value="CodeableConcept" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:ProcedureOperationIMRI.reasonReference.Reference(TWCoreCondition).code.coding.code" /> </mapping> </element> <element id="OperationNoteModel.operation.postoperativeDiagnosis[x]"> <path value="OperationNoteModel.operation.postoperativeDiagnosis[x]" /> <short value="手術後診斷" /> <definition value="手術後診斷" /> <min value="0" /> <max value="*" /> <type> <code value="Narrative" /> </type> <type> <code value="CodeableConcept" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:CompositionOperationNoteIMRI.section:OperationNote.section:postoperativeDiagnosis.text 或 entry:TWCoreCondition.code.coding.code" /> </mapping> </element> <element id="OperationNoteModel.operation.operationCode"> <path value="OperationNoteModel.operation.operationCode" /> <short value="手術代碼" /> <definition value="手術代碼" /> <min value="1" /> <max value="1" /> <type> <code value="CodeableConcept" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:ProcedureOperationIMRI.code.coding.code" /> </mapping> </element> <element id="OperationNoteModel.operation.bodyPart"> <path value="OperationNoteModel.operation.bodyPart" /> <short value="手術部位" /> <definition value="手術部位" /> <min value="0" /> <max value="*" /> <type> <code value="CodeableConcept" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:ProcedureOperationIMRI.bodySite" /> </mapping> </element> <element id="OperationNoteModel.operation.indication"> <path value="OperationNoteModel.operation.indication" /> <short value="手術目的" /> <definition value="手術目的" /> <min value="1" /> <max value="1" /> <type> <code value="string" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:ProcedureOperationIMRI.code.coding.display" /> </mapping> </element> <element id="OperationNoteModel.operation.bloodLoss[x]"> <path value="OperationNoteModel.operation.bloodLoss[x]" /> <short value="失血量" /> <definition value="失血量" /> <min value="0" /> <max value="1" /> <type> <code value="Narrative" /> </type> <type> <code value="decimal" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:CompositionOperationNoteIMRI.section:OperationNote.section:bloodLoss.text 或 entry:ObservationBloodLossIMRI.valueQuantity.value" /> </mapping> </element> <element id="OperationNoteModel.operation.anesthesiaMode[x]"> <path value="OperationNoteModel.operation.anesthesiaMode[x]" /> <short value="麻醉模式" /> <definition value="麻醉模式" /> <min value="0" /> <max value="1" /> <type> <code value="Narrative" /> </type> <type> <code value="CodeableConcept" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:CompositionOperationNoteIMRI.section:OperationNote.section:anesthesiaMode.text 或 entry:ProcedureAnesthesiaModeIMRI.code" /> </mapping> </element> <element id="OperationNoteModel.operation.anesthesiologist"> <path value="OperationNoteModel.operation.anesthesiologist" /> <short value="麻醉醫師" /> <definition value="麻醉醫師" /> <min value="0" /> <max value="*" /> <type> <code value="HumanName" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:ProcedureAnesthesiaModeIMRI.performer.actor.Reference(PractitionerRoleIMRI).where(code = '88189002').practitioner.Reference(PractitionerIMRI).name" /> </mapping> </element> <element id="OperationNoteModel.operation.operativeFinding"> <path value="OperationNoteModel.operation.operativeFinding" /> <short value="手術發現" /> <definition value="手術發現" /> <min value="1" /> <max value="*" /> <type> <code value="markdown" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:ProcedureOperationIMRI.note[0].text" /> </mapping> </element> <element id="OperationNoteModel.operation.operationProcedure"> <path value="OperationNoteModel.operation.operationProcedure" /> <short value="手術過程紀錄" /> <definition value="手術過程紀錄" /> <min value="1" /> <max value="*" /> <type> <code value="markdown" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:ProcedureOperationIMRI.note[1].text" /> </mapping> </element> <element id="OperationNoteModel.operation.device"> <path value="OperationNoteModel.operation.device" /> <short value="手術特材" /> <definition value="手術特材" /> <min value="0" /> <max value="*" /> <type> <code value="CodeableConcept" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:ProcedureOperationIMRI.usedCode" /> </mapping> </element> <element id="OperationNoteModel.operation.surgeon"> <path value="OperationNoteModel.operation.surgeon" /> <short value="手術醫師" /> <definition value="手術醫師" /> <min value="0" /> <max value="*" /> <type> <code value="HumanName" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:ProcedureOperationIMRI.performer.actor.Reference(PractitionerRoleIMRI).where(code = '304292004').practitioner.Reference(PractitionerIMRI).name" /> </mapping> </element> <element id="OperationNoteModel.operation.surgicalImage"> <path value="OperationNoteModel.operation.surgicalImage" /> <short value="手術圖像" /> <definition value="手術圖像" /> <min value="0" /> <max value="*" /> <type> <code value="url" /> </type> <mapping> <identity value="OperationNote" /> <map value="entry:ProcedureOperationIMRI.report.Reference(TWCoreDocumentReference).content.attachment.url" /> </mapping> </element> </differential> </StructureDefinition>