醫療影像及報告實作指引
0.1.0 - DSTU0 ci-build

醫療影像及報告實作指引 - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: DiagnosticReport Image

Official URL: https://hapi.fhir.tw/fhir/StructureDefinition/DiagnosticReport-Image Version: 0.1.0
Active as of 2024-07-29 Computable Name: ImageDiagnosticReport

此Profile說明本IG如何進一步定義FHIR的DiagnosticReport Resource以呈現影像報告之內容

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from DiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport 診斷報告—由請求資訊、不可被中斷的一個或一系列結果（atomic results）、影像、解釋以及格式化報告所組成。
... identifier S 1..1 Identifier 報告的業務用識別碼。[應填入於醫學影像報告檢查單號Accession No.]
.... system S 1..1 uri 機構識別碼（identifier）的命名空間（namespace）
.... value S 1..1 string 檢查單號(Accession No.)
... status S 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category S 1..1 CodeableConcept Service category
Binding: ImagingStudy Category Type (required)
.... coding 1..* Coding 由專門術語系統（terminology system）定義的代碼
..... system 1..1 uri 專門術語系統（terminology system）的識別
..... code 1..1 code 系統定義的語法之符號
..... display 1..1 string 由系統定義的表示法
.... Slices for coding 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:icd10-pcs-2023-b S 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-PCS-B-Imaging值集 (required)
...... system S 1..1 uri Identity of the terminology system
Required Pattern: https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-b
...... code S 1..1 code Symbol in syntax defined by the system
...... display S 1..1 string Representation defined by the system
..... coding:icd10-pcs-2023-c S 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-PCS-C-Nuclear Medicine 值集 (required)
...... system S 1..1 uri Identity of the terminology system
Required Pattern: https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-c
...... code S 1..1 code Symbol in syntax defined by the system
...... display S 1..1 string Representation defined by the system
..... coding:icd10-pcs-2023-d S 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-PCS-D-Radiation Therapy值集 (required)
...... system S 1..1 uri Identity of the terminology system
Required Pattern: https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-d
...... code S 1..1 code Symbol in syntax defined by the system
...... display S 1..1 string Representation defined by the system
... subject S 1..1 Reference(Patient) 報告的對象—通常但不總是病人
... encounter S 0..1 Reference(Encounter) 請求醫療資源時的健康照護事件
... effective[x] S 1..1 dateTime, Period 與臨床相關的時間／報告的時段。[應填入醫學影像報告確認報告時間Verification Time]
... issued S 0..1 instant 此版本完成的日期時間
... performer S 1..* Reference(Practitioner | Organization) 對診斷服務負責者。[應連結醫學影像報告報告醫師姓名Verification Physician]
... resultsInterpreter S 0..* Reference(Practitioner | Organization) 主要結果的解釋者
... specimen S 0..* Reference(Specimen) 此報告所依據的檢體
... result S 1..* Reference(Observation Imaging result) 診斷結果(Finding)
... imagingStudy S 0..* Reference(ImagingStudy) 參照至與診斷報告相關的成像之全部細節
... media S 0..* BackboneElement 與此報告相關的關鍵影像
.... comment S 0..1 string 關於影像的意見（例如：解釋）。
.... link S 1..1 Reference(Media) 參照的影像來源
... conclusion S 1..1 string 診斷結果的臨床結論（interpretation/impression）。[應填入醫學影像報告報告結果Records. Total]
... conclusionCode S 0..* CodeableConcept 診斷結果的臨床結論的代碼，此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。
Binding: SNOMEDCTClinicalFindings (example)
... presentedForm 0..* Attachment 已發佈的整個報告

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryrequiredImageCategory
https://hapi.fhir.tw/fhir/ValueSet/ImageCategory
from this IG
DiagnosticReport.code.coding:icd10-pcs-2023-brequiredICD10PCSB (a valid code from 臺灣2023年中文版ICD-10-PCS-B-Imaging)
https://hapi.fhir.tw/fhir/ValueSet/icd-10-pcs-2023-tw-b
from this IG
DiagnosticReport.code.coding:icd10-pcs-2023-crequiredICD10PCSC (a valid code from 臺灣2023年中文版ICD-10-PCS-C-NuclearMedicine)
https://hapi.fhir.tw/fhir/ValueSet/icd-10-pcs-2023-tw-c
from this IG
DiagnosticReport.code.coding:icd10-pcs-2023-drequiredICD10PCSD (a valid code from 臺灣2023年中文版ICD-10-PCS-D-RadiationTherapy)
https://hapi.fhir.tw/fhir/ValueSet/icd-10-pcs-2023-tw-d
from this IG
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport 診斷報告—由請求資訊、不可被中斷的一個或一系列結果（atomic results）、影像、解釋以及格式化報告所組成。
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier 報告的業務用識別碼。[應填入於醫學影像報告檢查單號Accession No.]
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... system SΣ 1..1 uri 機構識別碼（identifier）的命名空間（namespace）
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string 檢查單號(Accession No.)
Example General: 123456
... category SΣ 1..1 CodeableConcept Service category
Binding: ImagingStudy Category Type (required)
.... coding Σ 1..* Coding 由專門術語系統（terminology system）定義的代碼
..... system Σ 1..1 uri 專門術語系統（terminology system）的識別
..... code Σ 1..1 code 系統定義的語法之符號
..... display Σ 1..1 string 由系統定義的表示法
... code SΣ 1..1 CodeableConcept 此診斷報告的名稱／代碼。[應填入於醫學影像報告疾病診斷Diagnosis ICD Code]
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

.... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:icd10-pcs-2023-b SΣ 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-PCS-B-Imaging值集 (required)
...... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-b
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display SΣ 1..1 string Representation defined by the system
..... coding:icd10-pcs-2023-c SΣ 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-PCS-C-Nuclear Medicine 值集 (required)
...... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-c
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display SΣ 1..1 string Representation defined by the system
..... coding:icd10-pcs-2023-d SΣ 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-PCS-D-Radiation Therapy值集 (required)
...... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-d
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display SΣ 1..1 string Representation defined by the system
... subject SΣ 1..1 Reference(Patient) 報告的對象—通常但不總是病人
... encounter SΣ 0..1 Reference(Encounter) 請求醫療資源時的健康照護事件
... effective[x] SΣ 1..1 與臨床相關的時間／報告的時段。[應填入醫學影像報告確認報告時間Verification Time]
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 0..1 instant 此版本完成的日期時間
... performer SΣ 1..* Reference(Practitioner | Organization) 對診斷服務負責者。[應連結醫學影像報告報告醫師姓名Verification Physician]
... resultsInterpreter SΣ 0..* Reference(Practitioner | Organization) 主要結果的解釋者
... specimen S 0..* Reference(Specimen) 此報告所依據的檢體
... result S 1..* Reference(Observation Imaging result) 診斷結果(Finding)
... imagingStudy S 0..* Reference(ImagingStudy) 參照至與診斷報告相關的成像之全部細節
... media SΣ 0..* BackboneElement 與此報告相關的關鍵影像
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... comment S 0..1 string 關於影像的意見（例如：解釋）。
.... link SΣ 1..1 Reference(Media) 參照的影像來源
... conclusion S 1..1 string 診斷結果的臨床結論（interpretation/impression）。[應填入醫學影像報告報告結果Records. Total]
... conclusionCode S 0..* CodeableConcept 診斷結果的臨床結論的代碼，此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。
Binding: SNOMEDCTClinicalFindings (example)
... presentedForm 0..* Attachment 已發佈的整個報告

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DiagnosticReport.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryrequiredImageCategory
https://hapi.fhir.tw/fhir/ValueSet/ImageCategory
from this IG
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/report-codes
from the FHIR Standard
DiagnosticReport.code.coding:icd10-pcs-2023-brequiredICD10PCSB (a valid code from 臺灣2023年中文版ICD-10-PCS-B-Imaging)
https://hapi.fhir.tw/fhir/ValueSet/icd-10-pcs-2023-tw-b
from this IG
DiagnosticReport.code.coding:icd10-pcs-2023-crequiredICD10PCSC (a valid code from 臺灣2023年中文版ICD-10-PCS-C-NuclearMedicine)
https://hapi.fhir.tw/fhir/ValueSet/icd-10-pcs-2023-tw-c
from this IG
DiagnosticReport.code.coding:icd10-pcs-2023-drequiredICD10PCSD (a valid code from 臺灣2023年中文版ICD-10-PCS-D-RadiationTherapy)
https://hapi.fhir.tw/fhir/ValueSet/icd-10-pcs-2023-tw-d
from this IG
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport 診斷報告—由請求資訊、不可被中斷的一個或一系列結果（atomic results）、影像、解釋以及格式化報告所組成。
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier 報告的業務用識別碼。[應填入於醫學影像報告檢查單號Accession No.]
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

.... system SΣ 1..1 uri 機構識別碼（identifier）的命名空間（namespace）
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string 檢查單號(Accession No.)
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... basedOn 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... status ?!SΣ 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category SΣ 1..1 CodeableConcept Service category
Binding: ImagingStudy Category Type (required)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 1..* Coding 由專門術語系統（terminology system）定義的代碼
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ 1..1 uri 專門術語系統（terminology system）的識別
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 1..1 code 系統定義的語法之符號
..... display Σ 1..1 string 由系統定義的表示法
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept 此診斷報告的名稱／代碼。[應填入於醫學影像報告疾病診斷Diagnosis ICD Code]
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:icd10-pcs-2023-b SΣ 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-PCS-B-Imaging值集 (required)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-b
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display SΣ 1..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:icd10-pcs-2023-c SΣ 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-PCS-C-Nuclear Medicine 值集 (required)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-c
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display SΣ 1..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:icd10-pcs-2023-d SΣ 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-PCS-D-Radiation Therapy值集 (required)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-d
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display SΣ 1..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) 報告的對象—通常但不總是病人
... encounter SΣ 0..1 Reference(Encounter) 請求醫療資源時的健康照護事件
... effective[x] SΣ 1..1 與臨床相關的時間／報告的時段。[應填入醫學影像報告確認報告時間Verification Time]
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 0..1 instant 此版本完成的日期時間
... performer SΣ 1..* Reference(Practitioner | Organization) 對診斷服務負責者。[應連結醫學影像報告報告醫師姓名Verification Physician]
... resultsInterpreter SΣ 0..* Reference(Practitioner | Organization) 主要結果的解釋者
... specimen S 0..* Reference(Specimen) 此報告所依據的檢體
... result S 1..* Reference(Observation Imaging result) 診斷結果(Finding)
... imagingStudy S 0..* Reference(ImagingStudy) 參照至與診斷報告相關的成像之全部細節
... media SΣ 0..* BackboneElement 與此報告相關的關鍵影像
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... comment S 0..1 string 關於影像的意見（例如：解釋）。
.... link SΣ 1..1 Reference(Media) 參照的影像來源
... conclusion S 1..1 string 診斷結果的臨床結論（interpretation/impression）。[應填入醫學影像報告報告結果Records. Total]
... conclusionCode S 0..* CodeableConcept 診斷結果的臨床結論的代碼，此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。
Binding: SNOMEDCTClinicalFindings (example)
... presentedForm 0..* Attachment 已發佈的整個報告

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DiagnosticReport.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
DiagnosticReport.identifier.typeextensibleIdentifier Type Codes
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryrequiredImageCategory
https://hapi.fhir.tw/fhir/ValueSet/ImageCategory
from this IG
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/report-codes
from the FHIR Standard
DiagnosticReport.code.coding:icd10-pcs-2023-brequiredICD10PCSB (a valid code from 臺灣2023年中文版ICD-10-PCS-B-Imaging)
https://hapi.fhir.tw/fhir/ValueSet/icd-10-pcs-2023-tw-b
from this IG
DiagnosticReport.code.coding:icd10-pcs-2023-crequiredICD10PCSC (a valid code from 臺灣2023年中文版ICD-10-PCS-C-NuclearMedicine)
https://hapi.fhir.tw/fhir/ValueSet/icd-10-pcs-2023-tw-c
from this IG
DiagnosticReport.code.coding:icd10-pcs-2023-drequiredICD10PCSD (a valid code from 臺灣2023年中文版ICD-10-PCS-D-RadiationTherapy)
https://hapi.fhir.tw/fhir/ValueSet/icd-10-pcs-2023-tw-d
from this IG
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from DiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport 診斷報告—由請求資訊、不可被中斷的一個或一系列結果（atomic results）、影像、解釋以及格式化報告所組成。
... identifier S 1..1 Identifier 報告的業務用識別碼。[應填入於醫學影像報告檢查單號Accession No.]
.... system S 1..1 uri 機構識別碼（identifier）的命名空間（namespace）
.... value S 1..1 string 檢查單號(Accession No.)
... status S 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category S 1..1 CodeableConcept Service category
Binding: ImagingStudy Category Type (required)
.... coding 1..* Coding 由專門術語系統（terminology system）定義的代碼
..... system 1..1 uri 專門術語系統（terminology system）的識別
..... code 1..1 code 系統定義的語法之符號
..... display 1..1 string 由系統定義的表示法
.... Slices for coding 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:icd10-pcs-2023-b S 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-PCS-B-Imaging值集 (required)
...... system S 1..1 uri Identity of the terminology system
Required Pattern: https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-b
...... code S 1..1 code Symbol in syntax defined by the system
...... display S 1..1 string Representation defined by the system
..... coding:icd10-pcs-2023-c S 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-PCS-C-Nuclear Medicine 值集 (required)
...... system S 1..1 uri Identity of the terminology system
Required Pattern: https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-c
...... code S 1..1 code Symbol in syntax defined by the system
...... display S 1..1 string Representation defined by the system
..... coding:icd10-pcs-2023-d S 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-PCS-D-Radiation Therapy值集 (required)
...... system S 1..1 uri Identity of the terminology system
Required Pattern: https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-d
...... code S 1..1 code Symbol in syntax defined by the system
...... display S 1..1 string Representation defined by the system
... subject S 1..1 Reference(Patient) 報告的對象—通常但不總是病人
... encounter S 0..1 Reference(Encounter) 請求醫療資源時的健康照護事件
... effective[x] S 1..1 dateTime, Period 與臨床相關的時間／報告的時段。[應填入醫學影像報告確認報告時間Verification Time]
... issued S 0..1 instant 此版本完成的日期時間
... performer S 1..* Reference(Practitioner | Organization) 對診斷服務負責者。[應連結醫學影像報告報告醫師姓名Verification Physician]
... resultsInterpreter S 0..* Reference(Practitioner | Organization) 主要結果的解釋者
... specimen S 0..* Reference(Specimen) 此報告所依據的檢體
... result S 1..* Reference(Observation Imaging result) 診斷結果(Finding)
... imagingStudy S 0..* Reference(ImagingStudy) 參照至與診斷報告相關的成像之全部細節
... media S 0..* BackboneElement 與此報告相關的關鍵影像
.... comment S 0..1 string 關於影像的意見（例如：解釋）。
.... link S 1..1 Reference(Media) 參照的影像來源
... conclusion S 1..1 string 診斷結果的臨床結論（interpretation/impression）。[應填入醫學影像報告報告結果Records. Total]
... conclusionCode S 0..* CodeableConcept 診斷結果的臨床結論的代碼，此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。
Binding: SNOMEDCTClinicalFindings (example)
... presentedForm 0..* Attachment 已發佈的整個報告

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryrequiredImageCategory
https://hapi.fhir.tw/fhir/ValueSet/ImageCategory
from this IG
DiagnosticReport.code.coding:icd10-pcs-2023-brequiredICD10PCSB (a valid code from 臺灣2023年中文版ICD-10-PCS-B-Imaging)
https://hapi.fhir.tw/fhir/ValueSet/icd-10-pcs-2023-tw-b
from this IG
DiagnosticReport.code.coding:icd10-pcs-2023-crequiredICD10PCSC (a valid code from 臺灣2023年中文版ICD-10-PCS-C-NuclearMedicine)
https://hapi.fhir.tw/fhir/ValueSet/icd-10-pcs-2023-tw-c
from this IG
DiagnosticReport.code.coding:icd10-pcs-2023-drequiredICD10PCSD (a valid code from 臺灣2023年中文版ICD-10-PCS-D-RadiationTherapy)
https://hapi.fhir.tw/fhir/ValueSet/icd-10-pcs-2023-tw-d
from this IG
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport 診斷報告—由請求資訊、不可被中斷的一個或一系列結果（atomic results）、影像、解釋以及格式化報告所組成。
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier 報告的業務用識別碼。[應填入於醫學影像報告檢查單號Accession No.]
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... system SΣ 1..1 uri 機構識別碼（identifier）的命名空間（namespace）
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string 檢查單號(Accession No.)
Example General: 123456
... category SΣ 1..1 CodeableConcept Service category
Binding: ImagingStudy Category Type (required)
.... coding Σ 1..* Coding 由專門術語系統（terminology system）定義的代碼
..... system Σ 1..1 uri 專門術語系統（terminology system）的識別
..... code Σ 1..1 code 系統定義的語法之符號
..... display Σ 1..1 string 由系統定義的表示法
... code SΣ 1..1 CodeableConcept 此診斷報告的名稱／代碼。[應填入於醫學影像報告疾病診斷Diagnosis ICD Code]
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

.... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:icd10-pcs-2023-b SΣ 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-PCS-B-Imaging值集 (required)
...... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-b
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display SΣ 1..1 string Representation defined by the system
..... coding:icd10-pcs-2023-c SΣ 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-PCS-C-Nuclear Medicine 值集 (required)
...... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-c
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display SΣ 1..1 string Representation defined by the system
..... coding:icd10-pcs-2023-d SΣ 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-PCS-D-Radiation Therapy值集 (required)
...... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-d
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display SΣ 1..1 string Representation defined by the system
... subject SΣ 1..1 Reference(Patient) 報告的對象—通常但不總是病人
... encounter SΣ 0..1 Reference(Encounter) 請求醫療資源時的健康照護事件
... effective[x] SΣ 1..1 與臨床相關的時間／報告的時段。[應填入醫學影像報告確認報告時間Verification Time]
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 0..1 instant 此版本完成的日期時間
... performer SΣ 1..* Reference(Practitioner | Organization) 對診斷服務負責者。[應連結醫學影像報告報告醫師姓名Verification Physician]
... resultsInterpreter SΣ 0..* Reference(Practitioner | Organization) 主要結果的解釋者
... specimen S 0..* Reference(Specimen) 此報告所依據的檢體
... result S 1..* Reference(Observation Imaging result) 診斷結果(Finding)
... imagingStudy S 0..* Reference(ImagingStudy) 參照至與診斷報告相關的成像之全部細節
... media SΣ 0..* BackboneElement 與此報告相關的關鍵影像
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... comment S 0..1 string 關於影像的意見（例如：解釋）。
.... link SΣ 1..1 Reference(Media) 參照的影像來源
... conclusion S 1..1 string 診斷結果的臨床結論（interpretation/impression）。[應填入醫學影像報告報告結果Records. Total]
... conclusionCode S 0..* CodeableConcept 診斷結果的臨床結論的代碼，此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。
Binding: SNOMEDCTClinicalFindings (example)
... presentedForm 0..* Attachment 已發佈的整個報告

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DiagnosticReport.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryrequiredImageCategory
https://hapi.fhir.tw/fhir/ValueSet/ImageCategory
from this IG
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/report-codes
from the FHIR Standard
DiagnosticReport.code.coding:icd10-pcs-2023-brequiredICD10PCSB (a valid code from 臺灣2023年中文版ICD-10-PCS-B-Imaging)
https://hapi.fhir.tw/fhir/ValueSet/icd-10-pcs-2023-tw-b
from this IG
DiagnosticReport.code.coding:icd10-pcs-2023-crequiredICD10PCSC (a valid code from 臺灣2023年中文版ICD-10-PCS-C-NuclearMedicine)
https://hapi.fhir.tw/fhir/ValueSet/icd-10-pcs-2023-tw-c
from this IG
DiagnosticReport.code.coding:icd10-pcs-2023-drequiredICD10PCSD (a valid code from 臺灣2023年中文版ICD-10-PCS-D-RadiationTherapy)
https://hapi.fhir.tw/fhir/ValueSet/icd-10-pcs-2023-tw-d
from this IG
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport 診斷報告—由請求資訊、不可被中斷的一個或一系列結果（atomic results）、影像、解釋以及格式化報告所組成。
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier 報告的業務用識別碼。[應填入於醫學影像報告檢查單號Accession No.]
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

.... system SΣ 1..1 uri 機構識別碼（identifier）的命名空間（namespace）
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string 檢查單號(Accession No.)
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... basedOn 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... status ?!SΣ 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category SΣ 1..1 CodeableConcept Service category
Binding: ImagingStudy Category Type (required)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 1..* Coding 由專門術語系統（terminology system）定義的代碼
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ 1..1 uri 專門術語系統（terminology system）的識別
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 1..1 code 系統定義的語法之符號
..... display Σ 1..1 string 由系統定義的表示法
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept 此診斷報告的名稱／代碼。[應填入於醫學影像報告疾病診斷Diagnosis ICD Code]
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:icd10-pcs-2023-b SΣ 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-PCS-B-Imaging值集 (required)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-b
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display SΣ 1..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:icd10-pcs-2023-c SΣ 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-PCS-C-Nuclear Medicine 值集 (required)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-c
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display SΣ 1..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:icd10-pcs-2023-d SΣ 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-PCS-D-Radiation Therapy值集 (required)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: https://hapi.fhir.tw/fhir/CodeSystem/icd-10-pcs-2023-tw-d
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display SΣ 1..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) 報告的對象—通常但不總是病人
... encounter SΣ 0..1 Reference(Encounter) 請求醫療資源時的健康照護事件
... effective[x] SΣ 1..1 與臨床相關的時間／報告的時段。[應填入醫學影像報告確認報告時間Verification Time]
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 0..1 instant 此版本完成的日期時間
... performer SΣ 1..* Reference(Practitioner | Organization) 對診斷服務負責者。[應連結醫學影像報告報告醫師姓名Verification Physician]
... resultsInterpreter SΣ 0..* Reference(Practitioner | Organization) 主要結果的解釋者
... specimen S 0..* Reference(Specimen) 此報告所依據的檢體
... result S 1..* Reference(Observation Imaging result) 診斷結果(Finding)
... imagingStudy S 0..* Reference(ImagingStudy) 參照至與診斷報告相關的成像之全部細節
... media SΣ 0..* BackboneElement 與此報告相關的關鍵影像
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... comment S 0..1 string 關於影像的意見（例如：解釋）。
.... link SΣ 1..1 Reference(Media) 參照的影像來源
... conclusion S 1..1 string 診斷結果的臨床結論（interpretation/impression）。[應填入醫學影像報告報告結果Records. Total]
... conclusionCode S 0..* CodeableConcept 診斷結果的臨床結論的代碼，此為SNOMED CT代碼，若機構已有購買相關授權，亦可使用。
Binding: SNOMEDCTClinicalFindings (example)
... presentedForm 0..* Attachment 已發佈的整個報告

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DiagnosticReport.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
DiagnosticReport.identifier.typeextensibleIdentifier Type Codes
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryrequiredImageCategory
https://hapi.fhir.tw/fhir/ValueSet/ImageCategory
from this IG
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/report-codes
from the FHIR Standard
DiagnosticReport.code.coding:icd10-pcs-2023-brequiredICD10PCSB (a valid code from 臺灣2023年中文版ICD-10-PCS-B-Imaging)
https://hapi.fhir.tw/fhir/ValueSet/icd-10-pcs-2023-tw-b
from this IG
DiagnosticReport.code.coding:icd10-pcs-2023-crequiredICD10PCSC (a valid code from 臺灣2023年中文版ICD-10-PCS-C-NuclearMedicine)
https://hapi.fhir.tw/fhir/ValueSet/icd-10-pcs-2023-tw-c
from this IG
DiagnosticReport.code.coding:icd10-pcs-2023-drequiredICD10PCSD (a valid code from 臺灣2023年中文版ICD-10-PCS-D-RadiationTherapy)
https://hapi.fhir.tw/fhir/ValueSet/icd-10-pcs-2023-tw-d
from this IG
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron