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: Condition

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

基於 TW CORE IG 的 Condition

Usage:

Formal Views of Profile Content

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

This structure is derived from TWCoreCondition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition TWCoreCondition
... code 1..1 CodeableConceptTW 病情、問題或診斷的識別。[應填入於醫學影像報告病史History of Present Illness]

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* TWCoreCondition 有關病情、問題或診斷的詳細資訊
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... implicitRules ?!Σ 0..1 uri 創建此內容所依據的一組規則
... modifierExtension ?! 0..* Extension 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。
... clinicalStatus S 1..1 CodeableConceptTW active | recurrence | relapse | inactive | remission | resolved ,病情、問題或診斷的臨床狀態。
Binding: ConditionClinicalStatusCodes (required): 應填入所綁定值集中的其中一個代碼。

... category S 1..1 CodeableConceptTW problem-list-item | encounter-diagnosis ,指定病情、問題或診斷的類別。
Binding: ConditionCategoryCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... severity S 0..1 CodeableConceptTW 病情、問題或診斷的主觀嚴重程度
Binding: Condition/DiagnosisSeverity (extensible): 臨床醫生對病情、問題或診斷嚴重程度的主觀評價;應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

... code S 1..1 CodeableConceptTW 病情、問題或診斷的識別。[應填入於醫學影像報告病史History of Present Illness]
Binding: Condition/Problem/DiagnosisCodes (example): 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。

.... Slices for coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。
Slice: Unordered, Open by pattern:$this
..... coding:icd10-cm-2021 S 0..1 CodingTW 此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。
Binding: 臺灣健保署2021年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。


..... coding:icd10-cm-2014 S 0..1 CodingTW 此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。
Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。


..... coding:icd9-cm-2001 S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required)
..... coding:absentOrUnknownProblem S 0..1 CodingTW 不存在的問題或未知問題的代碼
Binding: Absent or Unknown Problems - IPS (required): 應填入所綁定值集中的其中一個代碼。


..... coding:sct S 0..1 CodingTW 此為SNOMED CT診斷代碼,若機構已有購買相關授權,亦可使用。
Binding: SNOMED CT診斷代碼值集 (required): 應填入所綁定值集中的其中一個代碼。


.... text SΣ 0..1 string 概念的文字表示法
... bodySite S 0..* CodeableConceptTW 如果相關請填寫解剖位置
Binding: SNOMEDCTBodyStructures (extensible): 描述解剖位置的代碼。可包括側面;應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... subject SΣ 1..1 Reference(TW Core Patient | Group) 誰有此病情、問題或診斷?
... onset[x] SΣ 0..1 估計的或實際的日期、日期—時間或年齡。
.... onsetDateTime dateTime
... abatement[x] SC 0..1 何時解決/緩解
.... abatementDateTime dateTime
... asserter SΣ 0..1 Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | RelatedPerson) 聲稱有此病情、問題或診斷的人
... note S 0..* Annotation 關於此Condition的附加資訊

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severityextensibleCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Condition.code.coding:icd10-cm-2021requiredTW2021ICD10CM
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2021-tw
Condition.code.coding:icd10-cm-2014requiredTW2014ICD10CM
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2014-tw
Condition.code.coding:icd9-cm-2001requiredTW2001ICD9CM
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw
Condition.code.coding:absentOrUnknownProblemrequiredAbsentOrUnknownProblemsUvIps
http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips
Condition.code.coding:sctrequiredTWConditionCodeSCT
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw
Condition.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
con-3best practiceConditionCondition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
: clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4errorConditionIf condition is abated, then clinicalStatus must be either inactive, resolved, or remission
: abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5errorConditionCondition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
: verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceConditionA 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
.. Condition C 0..* TWCoreCondition 有關病情、問題或診斷的詳細資訊
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... id Σ 0..1 id 不重複的ID用以識別儲存在特定FHIR Server中的Condition紀錄,通常又稱為邏輯性ID。
... meta Σ 0..1 Meta 此Condition Resource的metadata
... implicitRules ?!Σ 0..1 uri 創建此內容所依據的一組規則
... text 0..1 Narrative Condition Resource之內容摘要以供人閱讀
... contained 0..* Resource 內嵌的(contained)、行內的Resources
... extension 0..* Extension 擴充的資料項目
... modifierExtension ?! 0..* Extension 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。
... identifier Σ 0..* Identifier 此病情、問題或診斷的外部識別碼
... clinicalStatus S 1..1 CodeableConceptTW active | recurrence | relapse | inactive | remission | resolved ,病情、問題或診斷的臨床狀態。
Binding: ConditionClinicalStatusCodes (required): 應填入所綁定值集中的其中一個代碼。

... verificationStatus S 0..1 CodeableConceptTW unconfirmed | provisional | differential | confirmed | refuted | entered-in-error ,支持或拒絕病情、問題或診斷的臨床狀態的驗證狀態。
Binding: ConditionVerificationStatus (required): 應填入所綁定值集中的其中一個代碼。

... category S 1..1 CodeableConceptTW problem-list-item | encounter-diagnosis ,指定病情、問題或診斷的類別。
Binding: ConditionCategoryCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... severity S 0..1 CodeableConceptTW 病情、問題或診斷的主觀嚴重程度
Binding: Condition/DiagnosisSeverity (extensible): 臨床醫生對病情、問題或診斷嚴重程度的主觀評價;應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

... code S 1..1 CodeableConceptTW 病情、問題或診斷的識別。[應填入於醫學影像報告病史History of Present Illness]
Binding: Condition/Problem/DiagnosisCodes (example): 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。

.... id 0..1 string 唯一可識別ID,以供資料項目間相互參照。
.... extension 0..* Extension 擴充的資料項目
Slice: Unordered, Open by value:url
.... Slices for coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。
Slice: Unordered, Open by pattern:$this
..... coding:icd10-cm-2021 S 0..1 CodingTW 此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。
Binding: 臺灣健保署2021年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。


..... coding:icd10-cm-2014 S 0..1 CodingTW 此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。
Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。


..... coding:icd9-cm-2001 S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required)
..... coding:absentOrUnknownProblem S 0..1 CodingTW 不存在的問題或未知問題的代碼
Binding: Absent or Unknown Problems - IPS (required): 應填入所綁定值集中的其中一個代碼。


..... coding:sct S 0..1 CodingTW 此為SNOMED CT診斷代碼,若機構已有購買相關授權,亦可使用。
Binding: SNOMED CT診斷代碼值集 (required): 應填入所綁定值集中的其中一個代碼。


.... text SΣ 0..1 string 概念的文字表示法
... bodySite S 0..* CodeableConceptTW 如果相關請填寫解剖位置
Binding: SNOMEDCTBodyStructures (extensible): 描述解剖位置的代碼。可包括側面;應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... subject SΣ 1..1 Reference(TW Core Patient | Group) 誰有此病情、問題或診斷?
... encounter Σ 0..1 Reference(TW Core Encounter) 作為病情、問題或診斷紀錄的一部分的就醫(Encounter)紀錄
... onset[x] SΣ 0..1 估計的或實際的日期、日期—時間或年齡。
.... onsetDateTime dateTime S
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
... abatement[x] SC 0..1 何時解決/緩解
.... abatementDateTime dateTime S
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
... recordedDate Σ 0..1 dateTime 記錄的日期
... recorder Σ 0..1 Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | RelatedPerson) 誰記錄此病情、問題或診斷
... asserter SΣ 0..1 Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | RelatedPerson) 聲稱有此病情、問題或診斷的人
... stage C 0..* BackboneElement 分期(stage)/分級(grade),通常是正式的評估。
con-1: Stage SHALL have summary or assessment
.... 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
.... summary 0..1 CodeableConceptTW 簡單的摘要(特定疾病)。
Binding: ConditionStage (extensible): 描述病情、問題或診斷分期的代碼(例如:癌症分期)。應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

.... assessment C 0..* Reference(ClinicalImpression | TW Core DiagnosticReport | TW Core Observation Laboratory Result | TW Core Observation Vital Signs) 正式的評估記錄
.... type 0..1 CodeableConceptTW 分期的種類
Binding: ConditionStageType (extensible): 病情、問題或診斷分期種類的代碼(如臨床或病理);應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

... evidence C 0..* BackboneElement 支持的證據
con-2: evidence SHALL have code or details
.... 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
.... code 0..* CodeableConceptTW 表現/症狀
Binding: ManifestationAndSymptomCodes (extensible): 病情、問題或診斷的表現或症狀之代碼;應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


.... detail ΣC 0..* Reference(Resource) 在其他地方找到的支持資訊
... note S 0..* Annotation 關於此Condition的附加資訊

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severityextensibleCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Condition.code.coding:icd10-cm-2021requiredTW2021ICD10CM
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2021-tw
Condition.code.coding:icd10-cm-2014requiredTW2014ICD10CM
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2014-tw
Condition.code.coding:icd9-cm-2001requiredTW2001ICD9CM
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw
Condition.code.coding:absentOrUnknownProblemrequiredAbsentOrUnknownProblemsUvIps
http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips
Condition.code.coding:sctrequiredTWConditionCodeSCT
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw
Condition.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Condition.stage.summaryextensibleConditionStage
http://hl7.org/fhir/ValueSet/condition-stage
from the FHIR Standard
Condition.stage.typeextensibleConditionStageType
http://hl7.org/fhir/ValueSet/condition-stage-type
from the FHIR Standard
Condition.evidence.codeextensibleManifestationAndSymptomCodes
http://hl7.org/fhir/ValueSet/manifestation-or-symptom
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
con-1errorCondition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
con-2errorCondition.evidenceevidence SHALL have code or details
: code.exists() or detail.exists()
con-3best practiceConditionCondition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
: clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4errorConditionIf condition is abated, then clinicalStatus must be either inactive, resolved, or remission
: abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5errorConditionCondition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
: verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceConditionA 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()

This structure is derived from TWCoreCondition

Summary

Mandatory: 1 element

Differential View

This structure is derived from TWCoreCondition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition TWCoreCondition
... code 1..1 CodeableConceptTW 病情、問題或診斷的識別。[應填入於醫學影像報告病史History of Present Illness]

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* TWCoreCondition 有關病情、問題或診斷的詳細資訊
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... implicitRules ?!Σ 0..1 uri 創建此內容所依據的一組規則
... modifierExtension ?! 0..* Extension 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。
... clinicalStatus S 1..1 CodeableConceptTW active | recurrence | relapse | inactive | remission | resolved ,病情、問題或診斷的臨床狀態。
Binding: ConditionClinicalStatusCodes (required): 應填入所綁定值集中的其中一個代碼。

... category S 1..1 CodeableConceptTW problem-list-item | encounter-diagnosis ,指定病情、問題或診斷的類別。
Binding: ConditionCategoryCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... severity S 0..1 CodeableConceptTW 病情、問題或診斷的主觀嚴重程度
Binding: Condition/DiagnosisSeverity (extensible): 臨床醫生對病情、問題或診斷嚴重程度的主觀評價;應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

... code S 1..1 CodeableConceptTW 病情、問題或診斷的識別。[應填入於醫學影像報告病史History of Present Illness]
Binding: Condition/Problem/DiagnosisCodes (example): 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。

.... Slices for coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。
Slice: Unordered, Open by pattern:$this
..... coding:icd10-cm-2021 S 0..1 CodingTW 此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。
Binding: 臺灣健保署2021年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。


..... coding:icd10-cm-2014 S 0..1 CodingTW 此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。
Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。


..... coding:icd9-cm-2001 S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required)
..... coding:absentOrUnknownProblem S 0..1 CodingTW 不存在的問題或未知問題的代碼
Binding: Absent or Unknown Problems - IPS (required): 應填入所綁定值集中的其中一個代碼。


..... coding:sct S 0..1 CodingTW 此為SNOMED CT診斷代碼,若機構已有購買相關授權,亦可使用。
Binding: SNOMED CT診斷代碼值集 (required): 應填入所綁定值集中的其中一個代碼。


.... text SΣ 0..1 string 概念的文字表示法
... bodySite S 0..* CodeableConceptTW 如果相關請填寫解剖位置
Binding: SNOMEDCTBodyStructures (extensible): 描述解剖位置的代碼。可包括側面;應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... subject SΣ 1..1 Reference(TW Core Patient | Group) 誰有此病情、問題或診斷?
... onset[x] SΣ 0..1 估計的或實際的日期、日期—時間或年齡。
.... onsetDateTime dateTime
... abatement[x] SC 0..1 何時解決/緩解
.... abatementDateTime dateTime
... asserter SΣ 0..1 Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | RelatedPerson) 聲稱有此病情、問題或診斷的人
... note S 0..* Annotation 關於此Condition的附加資訊

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severityextensibleCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Condition.code.coding:icd10-cm-2021requiredTW2021ICD10CM
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2021-tw
Condition.code.coding:icd10-cm-2014requiredTW2014ICD10CM
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2014-tw
Condition.code.coding:icd9-cm-2001requiredTW2001ICD9CM
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw
Condition.code.coding:absentOrUnknownProblemrequiredAbsentOrUnknownProblemsUvIps
http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips
Condition.code.coding:sctrequiredTWConditionCodeSCT
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw
Condition.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
con-3best practiceConditionCondition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
: clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4errorConditionIf condition is abated, then clinicalStatus must be either inactive, resolved, or remission
: abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5errorConditionCondition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
: verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceConditionA 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
.. Condition C 0..* TWCoreCondition 有關病情、問題或診斷的詳細資訊
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... id Σ 0..1 id 不重複的ID用以識別儲存在特定FHIR Server中的Condition紀錄,通常又稱為邏輯性ID。
... meta Σ 0..1 Meta 此Condition Resource的metadata
... implicitRules ?!Σ 0..1 uri 創建此內容所依據的一組規則
... text 0..1 Narrative Condition Resource之內容摘要以供人閱讀
... contained 0..* Resource 內嵌的(contained)、行內的Resources
... extension 0..* Extension 擴充的資料項目
... modifierExtension ?! 0..* Extension 此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。
... identifier Σ 0..* Identifier 此病情、問題或診斷的外部識別碼
... clinicalStatus S 1..1 CodeableConceptTW active | recurrence | relapse | inactive | remission | resolved ,病情、問題或診斷的臨床狀態。
Binding: ConditionClinicalStatusCodes (required): 應填入所綁定值集中的其中一個代碼。

... verificationStatus S 0..1 CodeableConceptTW unconfirmed | provisional | differential | confirmed | refuted | entered-in-error ,支持或拒絕病情、問題或診斷的臨床狀態的驗證狀態。
Binding: ConditionVerificationStatus (required): 應填入所綁定值集中的其中一個代碼。

... category S 1..1 CodeableConceptTW problem-list-item | encounter-diagnosis ,指定病情、問題或診斷的類別。
Binding: ConditionCategoryCodes (extensible): 應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... severity S 0..1 CodeableConceptTW 病情、問題或診斷的主觀嚴重程度
Binding: Condition/DiagnosisSeverity (extensible): 臨床醫生對病情、問題或診斷嚴重程度的主觀評價;應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

... code S 1..1 CodeableConceptTW 病情、問題或診斷的識別。[應填入於醫學影像報告病史History of Present Illness]
Binding: Condition/Problem/DiagnosisCodes (example): 此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。

.... id 0..1 string 唯一可識別ID,以供資料項目間相互參照。
.... extension 0..* Extension 擴充的資料項目
Slice: Unordered, Open by value:url
.... Slices for coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼。此資料項目為可擴充綁定預設國際標準值集,但實作者可視實務專案需求只綁定以下slices中的任一值集。目前未只限定綁定預設值集是因為尚無slice值集與預設國際標準值集的代碼對應表,待後續有相對的代碼對應表後將建議採用國際標準值集作為唯一綁定值集並針對該值集進行擴充與管理,以利進行跨國與跨系統之資料交換。
Slice: Unordered, Open by pattern:$this
..... coding:icd10-cm-2021 S 0..1 CodingTW 此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。
Binding: 臺灣健保署2021年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。


..... coding:icd10-cm-2014 S 0..1 CodingTW 此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。
Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (required): 病情、問題或診斷的識別;應填入所綁定值集中的其中一個代碼。


..... coding:icd9-cm-2001 S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 臺灣健保署2001年中文版ICD-9-CM值集 (required)
..... coding:absentOrUnknownProblem S 0..1 CodingTW 不存在的問題或未知問題的代碼
Binding: Absent or Unknown Problems - IPS (required): 應填入所綁定值集中的其中一個代碼。


..... coding:sct S 0..1 CodingTW 此為SNOMED CT診斷代碼,若機構已有購買相關授權,亦可使用。
Binding: SNOMED CT診斷代碼值集 (required): 應填入所綁定值集中的其中一個代碼。


.... text SΣ 0..1 string 概念的文字表示法
... bodySite S 0..* CodeableConceptTW 如果相關請填寫解剖位置
Binding: SNOMEDCTBodyStructures (extensible): 描述解剖位置的代碼。可包括側面;應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


... subject SΣ 1..1 Reference(TW Core Patient | Group) 誰有此病情、問題或診斷?
... encounter Σ 0..1 Reference(TW Core Encounter) 作為病情、問題或診斷紀錄的一部分的就醫(Encounter)紀錄
... onset[x] SΣ 0..1 估計的或實際的日期、日期—時間或年齡。
.... onsetDateTime dateTime S
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
... abatement[x] SC 0..1 何時解決/緩解
.... abatementDateTime dateTime S
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
... recordedDate Σ 0..1 dateTime 記錄的日期
... recorder Σ 0..1 Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | RelatedPerson) 誰記錄此病情、問題或診斷
... asserter SΣ 0..1 Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Patient | RelatedPerson) 聲稱有此病情、問題或診斷的人
... stage C 0..* BackboneElement 分期(stage)/分級(grade),通常是正式的評估。
con-1: Stage SHALL have summary or assessment
.... 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
.... summary 0..1 CodeableConceptTW 簡單的摘要(特定疾病)。
Binding: ConditionStage (extensible): 描述病情、問題或診斷分期的代碼(例如:癌症分期)。應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

.... assessment C 0..* Reference(ClinicalImpression | TW Core DiagnosticReport | TW Core Observation Laboratory Result | TW Core Observation Vital Signs) 正式的評估記錄
.... type 0..1 CodeableConceptTW 分期的種類
Binding: ConditionStageType (extensible): 病情、問題或診斷分期種類的代碼(如臨床或病理);應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。

... evidence C 0..* BackboneElement 支持的證據
con-2: evidence SHALL have code or details
.... 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
.... code 0..* CodeableConceptTW 表現/症狀
Binding: ManifestationAndSymptomCodes (extensible): 病情、問題或診斷的表現或症狀之代碼;應填入所綁定值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


.... detail ΣC 0..* Reference(Resource) 在其他地方找到的支持資訊
... note S 0..* Annotation 關於此Condition的附加資訊

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severityextensibleCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Condition.code.coding:icd10-cm-2021requiredTW2021ICD10CM
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2021-tw
Condition.code.coding:icd10-cm-2014requiredTW2014ICD10CM
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2014-tw
Condition.code.coding:icd9-cm-2001requiredTW2001ICD9CM
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-9-cm-2001-tw
Condition.code.coding:absentOrUnknownProblemrequiredAbsentOrUnknownProblemsUvIps
http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips
Condition.code.coding:sctrequiredTWConditionCodeSCT
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/condition-code-sct-tw
Condition.bodySiteextensibleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Condition.stage.summaryextensibleConditionStage
http://hl7.org/fhir/ValueSet/condition-stage
from the FHIR Standard
Condition.stage.typeextensibleConditionStageType
http://hl7.org/fhir/ValueSet/condition-stage-type
from the FHIR Standard
Condition.evidence.codeextensibleManifestationAndSymptomCodes
http://hl7.org/fhir/ValueSet/manifestation-or-symptom
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
con-1errorCondition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
con-2errorCondition.evidenceevidence SHALL have code or details
: code.exists() or detail.exists()
con-3best practiceConditionCondition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
: clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4errorConditionIf condition is abated, then clinicalStatus must be either inactive, resolved, or remission
: abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5errorConditionCondition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
: verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceConditionA 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()

This structure is derived from TWCoreCondition

Summary

Mandatory: 1 element

 

Other representations of profile: CSV, Excel, Schematron