Package | tw.cathay.fhir.imri |
Type | StructureDefinition |
Id | Id |
FHIR Version | R4 |
Source | https://imri.cgh.org.tw/imri/https://simplifier.net/resolve?scope=tw.cathay.fhir.imri@1.0.0&canonical=https://imri.cgh.org.tw/imri/StructureDefinition/composition-dischargesummary-imri |
Url | https://imri.cgh.org.tw/imri/StructureDefinition/composition-dischargesummary-imri |
Version | 0.1.0 |
Status | active |
Date | 2024-11-26T22:24:42+08:00 |
Name | CompositionDischargeSummaryIMRI |
Title | CompositionDischargeSummary IMRI |
Experimental | False |
Realm | tw |
Description | 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。 |
Type | Composition |
Kind | resource |
CapabilityStatement | |
CapabilityStatementIMRIClient | 醫查-用戶端(IMRI Client) |
CapabilityStatementIMRIServer | 醫查-伺服端(IMRI Server) |
https://imri.cgh.org.tw/imri/StructureDefinition/bundle-dischargesummary-imri | BundleDischargeSummary IMRI |
Note: links and images are rebased to the (stated) source
Generated Narrative: StructureDefinition composition-dischargesummary-imri
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 | SC | 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 | SC | 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 | SC | 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 | |