Package | tw.gov.mohw.emr |
Type | StructureDefinition |
Id | Id |
FHIR Version | R4 |
Source | https://twcore.mohw.gov.tw/ig/emr/https://twcore.mohw.gov.tw/ig/emr/0.1.0/StructureDefinition-PMRComposition.html |
Url | https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRComposition |
Version | 0.1.0 |
Status | draft |
Date | 2024-05-06T17:38:33+08:00 |
Name | PMRComposition |
Title | 門診病歷-報告文件 |
Experimental | False |
Realm | tw |
Authority | national |
Description | 此Profile用於描述門診病歷的報告文件 |
Type | Composition |
Kind | resource |
CapabilityStatement | |
CapabilityStatementEMRClient ![]() | 電子病歷交換單張-用戶端 |
CapabilityStatementEMRServer ![]() | 電子病歷交換單張-伺服端 |
https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRBundle ![]() | 門診病歷-Bundle |
StructureDefinition | |
https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Composition-twcore ![]() | TW Core Composition |
Coverage-EMR ![]() | 電子處方箋/調劑單張-就醫身分別 |
PMRAllergyIntolerance ![]() | 門診病歷-過敏史 |
PMRClinicalImpressionAssessment ![]() | 門診病歷-評估_ Assessment |
PMRClinicalImpressionObjective ![]() | 門診病歷-客觀描述_ Objective |
PMRClinicalImpressionSubjective ![]() | 門診病歷-主觀描述_Subjective |
PMRConditionDiagnosis ![]() | 門診病歷-診斷 |
PMRConditionMajorIllness ![]() | 門診病歷-重大傷病 |
PMREncounter ![]() | 門診病歷-門診日期、科別 |
PMRFamilyTreeMedia ![]() | 門診病歷-家族圖譜 |
PMRMedication ![]() | 門診病歷-藥物處方內容(Medication) |
PMRMedicationRequest ![]() | 門診病歷-處方內容(MedicationRequest) |
PMRObservationLabResults ![]() | 門診病歷-實驗室檢查紀錄 |
PMROrganization ![]() | 門診病歷-醫事機構 |
PMROutpatientImageMedia ![]() | 門診病歷-門診圖像 |
PMRPatient ![]() | 門診病歷-病人基本資料 |
PMRPractitioner ![]() | 門診病歷-醫師姓名 |
PMRProcedure ![]() | 門診病歷-處置項目 |
PMRProfessionObservation ![]() | 門診病歷-職業 |
Note: links and images are rebased to the (stated) source
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
![]() ![]() | 0..* | TWCoreComposition | 將一組resources組成一份連貫的臨床聲明,並附有臨床證明。 | |
![]() ![]() ![]() | 1..1 | code | registered | partial | preliminary | final | amended | corrected + Binding: CompositionStatus (required): 診斷報告狀態;應填入Composition的代碼表中的其中一個代碼 Fixed Value: final | |
![]() ![]() ![]() | ||||
![]() ![]() ![]() ![]() | 1..1 | string | 類型說明描述 Fixed Value: 門診病歷 | |
![]() ![]() ![]() | 0..1 | Reference(門診病歷-病人基本資料) | 報告文件有關的對象及(或)事物。 | |
![]() ![]() ![]() ![]() | S | 1..1 | string | 關聯至門診病歷中的病人基本資料 |
![]() ![]() ![]() | S | 1..1 | Reference(門診病歷-門診日期、科別) | 報告文件來自於哪次住院基本資料。 |
![]() ![]() ![]() ![]() | S | 1..1 | string | 關聯至門診病歷中的門診日期、科別 |
![]() ![]() ![]() | 1..1 | dateTime | 報告產生日期 | |
![]() ![]() ![]() | 1..* | Reference(門診病歷-醫事機構 | 門診病歷-醫師姓名) | 報告文件有關的創作部分。關聯至門診病歷中的醫事機構或醫師姓名 | |
![]() ![]() ![]() | 1..1 | string | 報告文件的名字或標題 Fixed Value: 門診病歷 | |
![]() ![]() ![]() | 8..* | BackboneElement | 報告文件與哪些資料有關 Slice: Unordered, Open by value:code.coding.code | |
![]() ![]() ![]() ![]() | 1..* | BackboneElement | 門診病歷中的病人基本資料_實驗室檢查紀錄 | |
![]() ![]() ![]() ![]() ![]() | 0..1 | string | 此筆關聯的資料標題為何? | |
![]() ![]() ![]() ![]() ![]() | 1..1 | CodeableConceptTW | 小節分類(建議) | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | CodingTW | 由專門術語系統(terminology system)定義的代碼 | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | 專門術語系統(terminology system)的識別 Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | 系統定義的語法之符號 Fixed Value: 19146-0 | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | string | 由系統定義的表示法 Fixed Value: Referral lab test results | |
![]() ![]() ![]() ![]() ![]() | 1..* | Reference(門診病歷-實驗室檢查紀錄) | 此筆關聯的資料 | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | string | 關聯至門診病歷中的病人基本資料_實驗室檢查紀錄 | |
![]() ![]() ![]() ![]() | 1..* | BackboneElement | 門診病歷中的病人基本資料_重大傷病 | |
![]() ![]() ![]() ![]() ![]() | 0..1 | string | 此筆關聯的資料標題為何? | |
![]() ![]() ![]() ![]() ![]() | 1..1 | CodeableConceptTW | 小節分類(建議) | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | CodingTW | 由專門術語系統(terminology system)定義的代碼 | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | 專門術語系統(terminology system)的識別 Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | 系統定義的語法之符號 Fixed Value: 11338-1 | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | string | 由系統定義的表示法 Fixed Value: History of Major illnesses and injuries Narrative | |
![]() ![]() ![]() ![]() ![]() | 1..* | Reference(門診病歷-重大傷病) | 此筆關聯的資料 | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | string | 關聯至門診病歷中的病人基本資料_重大傷病 | |
![]() ![]() ![]() ![]() | 1..* | BackboneElement | 門診病歷中的病人基本資料_過敏史 | |
![]() ![]() ![]() ![]() ![]() | 0..1 | string | 此筆關聯的資料標題為何? | |
![]() ![]() ![]() ![]() ![]() | 1..1 | CodeableConceptTW | 小節分類(建議) | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | CodingTW | 由專門術語系統(terminology system)定義的代碼 | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | 專門術語系統(terminology system)的識別 Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | 系統定義的語法之符號 Fixed Value: 10155-0 | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | string | 由系統定義的表示法 Fixed Value: History of allergies, reported | |
![]() ![]() ![]() ![]() ![]() | 1..* | Reference(門診病歷-過敏史) | 此筆關聯的資料 | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | string | 關聯至門診病歷中的病人基本資料_過敏史 | |
![]() ![]() ![]() ![]() | 0..1 | BackboneElement | 門診病歷中的病人基本資料_職業 | |
![]() ![]() ![]() ![]() ![]() | 0..1 | string | 此筆關聯的資料標題為何? | |
![]() ![]() ![]() ![]() ![]() | 1..1 | CodeableConceptTW | 小節分類(建議) | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | CodingTW | 由專門術語系統(terminology system)定義的代碼 | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | 專門術語系統(terminology system)的識別 Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | 系統定義的語法之符號 Fixed Value: 21847-9 | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | string | 由系統定義的表示法 Fixed Value: Usual occupation Narrative | |
![]() ![]() ![]() ![]() ![]() | 1..* | Reference(門診病歷-職業) | 此筆關聯的資料 | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | string | 關聯至門診病歷中的病人基本資料_職業 | |
![]() ![]() ![]() ![]() | 1..1 | BackboneElement | 門診病歷中的病人基本資料_就醫身分別 | |
![]() ![]() ![]() ![]() ![]() | 0..1 | string | 此筆關聯的資料標題為何? | |
![]() ![]() ![]() ![]() ![]() | 1..1 | CodeableConceptTW | 小節分類(建議) | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | CodingTW | 由專門術語系統(terminology system)定義的代碼 | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | 專門術語系統(terminology system)的識別 Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | 系統定義的語法之符號 Fixed Value: 63513-6 | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | string | 由系統定義的表示法 Fixed Value: Are you covered by health insurance or some other kind of health care plan [PhenX] | |
![]() ![]() ![]() ![]() ![]() | 1..* | Reference(電子處方箋/調劑單張-就醫身分別) | 此筆關聯的資料 | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | string | 關聯至門診病歷中的病人基本資料_就醫身分別 | |
![]() ![]() ![]() ![]() | 1..* | BackboneElement | 門診病歷中的診斷 | |
![]() ![]() ![]() ![]() ![]() | 0..1 | string | 此筆關聯的資料標題為何? | |
![]() ![]() ![]() ![]() ![]() | 1..1 | CodeableConceptTW | 小節分類(建議) | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | CodingTW | 由專門術語系統(terminology system)定義的代碼 | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | 專門術語系統(terminology system)的識別 Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | 系統定義的語法之符號 Fixed Value: 29548-5 | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | string | 由系統定義的表示法 Fixed Value: Diagnosis Narrative | |
![]() ![]() ![]() ![]() ![]() | 1..* | Reference(門診病歷-診斷) | 此筆關聯的資料 | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | string | 關聯至門診病歷中的診斷 | |
![]() ![]() ![]() ![]() | 1..1 | BackboneElement | 門診病歷中的診斷病情摘要 | |
![]() ![]() ![]() ![]() ![]() | 0..1 | string | 此筆關聯的資料標題為何? | |
![]() ![]() ![]() ![]() ![]() | 1..1 | CodeableConceptTW | 小節分類(建議) | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | CodingTW | 由專門術語系統(terminology system)定義的代碼 | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | 專門術語系統(terminology system)的識別 Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | 系統定義的語法之符號 Fixed Value: 19824-2 | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 0..1 | string | 由系統定義的表示法 Fixed Value: Return visit conditions | |
![]() ![]() ![]() ![]() ![]() | 3..* | Reference(門診病歷-主觀描述_Subjective | 門診病歷-客觀描述_ Objective | 門診病歷-評估_ Assessment) | 此筆關聯的資料 Slice: Unordered, Open by value:identifier.value | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Reference(門診病歷-主觀描述_Subjective) | 提供一個連結用於參照或查看支持此小節內容的資料 | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | string | 關聯至門診病歷中的診斷病情摘要_Subjective | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | Identifier | Logical reference, when literal reference is not known | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | The namespace for the identifier value Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | string | The value that is unique Fixed Value: 61150-9 | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Reference(門診病歷-客觀描述_ Objective) | 提供一個連結用於參照或查看支持此小節內容的資料 | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | string | 關聯至門診病歷中的病人基本資料_Objective | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | Identifier | Logical reference, when literal reference is not known | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | The namespace for the identifier value Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | string | The value that is unique Fixed Value: 61149-1 | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Reference(門診病歷-評估_ Assessment) | 提供一個連結用於參照或查看支持此小節內容的資料 | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | string | 關聯至門診病歷中的病人基本資料_ Assessment | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | Identifier | Logical reference, when literal reference is not known | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | The namespace for the identifier value Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | string | The value that is unique Fixed Value: 11494-2 | |
![]() ![]() ![]() ![]() | 1..* | BackboneElement | 門診病歷中的處置項目 | |
![]() ![]() ![]() ![]() ![]() | 0..1 | string | 此筆關聯的資料標題為何? | |