This page is part of the 診所門診病摘實作指引 (v1.0.1: Releases) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

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Resource Profile: 文件參照(DocumentReference ClinEMR)

此文件參照(DocumentReference ClinEMR)Profile說明本IG如何進一步定義臺灣核心-文件參照(TW Core DocumentReference) Profile以呈現西醫/牙醫/中醫診所門診病摘之文件參照的詳細資料。

Usage:

• Use this Resource Profile: 牙醫-資料交換基本單位(Bundle DCR), 西醫-資料交換基本單位(Bundle MCR) and 中醫-資料交換基本單位(Bundle TCMCR)
• Refer to this Resource Profile: 關懷計畫(CarePlan ClinEMR), 牙醫-臨床文件架構(Composition DCR), 西醫-臨床文件架構(Composition MCR), 中醫-臨床文件架構(Composition TCMCR)... Show 20 more, 文件參照(DocumentReference ClinEMR), 檢驗檢查(Observation ClinEMR), 血壓(ObservationBloodPressureClinEMR ClinEMR), 血型(ObservationBloodtype ClinEMR), 身高(ObservationBodyHeight ClinEMR), 體溫(ObservationBodyTemp ClinEMR), 體重(ObservationBodyWeight ClinEMR), 教育程度(ObservationEducationLevel ClinEMR), 脈搏(ObservationHeartRate ClinEMR), 重大傷病註記(ObservationMajorIllness ClinEMR), 病人證型(ObservationManifestation TCMCR), 職業(ObservationOccupation ClinEMR), 病人脈象(ObservationPulseCondition TCMCR), 病人治則(ObservationTherapeuticDiscipline TCMCR), 病人舌象(ObservationTongueCondition TCMCR), 生命徵象(ObservationVitalSigns ClinEMR), 牙醫-處置或手術(Procedure DCR), 西醫-處置或手術(Procedure MCR), 中醫-處置或手術(Procedure TCMCR) and 服務請求(ServiceRequest ClinEMR)
• Examples for this Resource Profile: DocumentReference/DocumentReferenceDCR-min, DocumentReference/DocumentReferenceMCR-min and DocumentReference/DocumentReferenceTCMCR-min

Formal Views of Profile Content

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

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	TWCoreDocumentReference	文件的參照 dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	創建此內容所依據的一組規則 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
masterIdentifier	SΣ	0..1	Identifier	主版本的識別碼 ele-1: All FHIR elements must have a @value or children
status	?!SΣ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): 文件參照的狀態；應填入所綁定值集中的其中一個代碼。 ele-1: All FHIR elements must have a @value or children Required Pattern: current
type	S	0..1	CodeableConceptTW	文件的類型（如果可能，使用 LOINC 代碼） Binding: LOINC Code Document Type值集 (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。 ele-1: All FHIR elements must have a @value or children
category	S	0..*	CodeableConceptTW	文件的類別 Binding: LOINC Document Class值集 (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。 ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(病人資料(Patient ClinEMR))	文件描述的對象是誰/是什麼？ ele-1: All FHIR elements must have a @value or children
date	SΣ	0..1	instant	文件參照的創建時間是何時？ ele-1: All FHIR elements must have a @value or children
author	SΣ	0..*	Reference(健康照護服務提供人員資料(Practitioner ClinEMR) | TW Core PractitionerRole | 醫事機構(Organization ClinEMR) | TW Core Implantable Device | 病人資料(Patient ClinEMR) | TW Core RelatedPerson)	誰以及/或什麼創建了文件 ele-1: All FHIR elements must have a @value or children
authenticator		0..1	Reference(健康照護服務提供人員資料(Practitioner ClinEMR) | TW Core PractitionerRole | 醫事機構(Organization ClinEMR))	誰/什麼對文件進行了認證 ele-1: All FHIR elements must have a @value or children
custodian		0..1	Reference(醫事機構(Organization ClinEMR))	維護此文件的機構 ele-1: All FHIR elements must have a @value or children
content	SΣ	1..*	BackboneElement	被參照的文件。[應填入門診病摘之圖檔報告檔名或附件檔名(title)] ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
attachment	SΣ	1..1	Attachment	存取文件的位置 ele-1: All FHIR elements must have a @value or children
Slices for extension				Content/Rules for all slices
position	S	0..1	CodeableConcept	[應填入牙醫診所門診病摘之圖檔報告牙位Image Position] URL: https://fhir.cohesiondata.com/clinemr/StructureDefinition/cohesion-position ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
contentType	SΣ	1..1	code	【因FHIR必填】Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. ele-1: All FHIR elements must have a @value or children Example General: text/plain; charset=UTF-8, image/png
data	S	1..1	base64Binary	資料之內容，必須轉成Base 64格式。 ele-1: All FHIR elements must have a @value or children
title	Σ	1..1	string	檔案名稱應包含副檔名。[應填入門診病摘之圖檔報告檔名Image File Name或附件檔名Reference Doc File Name] ele-1: All FHIR elements must have a @value or children Example General: Official Corporate Logo
context	SΣ	0..1	BackboneElement	文件的臨床背景 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
encounter		0..*	Reference(就醫事件(Encounter ClinEMR))	文件內容的臨床背景 ele-1: All FHIR elements must have a @value or children
sourcePatientInfo		0..1	Reference(病人資料(Patient ClinEMR))	來源的病人人口統計資料 ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
DocumentReference.status	required	Pattern: current http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard
DocumentReference.type	extensible	LOINCDocumentType https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-type-doc-code
DocumentReference.category	extensible	LOINCDocumentClass https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-document-classcodes
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13) http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard

This structure is derived from TWCoreDocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference			TWCoreDocumentReference
status		1..1	code	current | superseded | entered-in-error Required Pattern: current
subject		1..1	Reference(病人資料(Patient ClinEMR))	文件描述的對象是誰/是什麼？
author		0..*	Reference(健康照護服務提供人員資料(Practitioner ClinEMR) | TW Core PractitionerRole | 醫事機構(Organization ClinEMR) | TW Core Implantable Device | 病人資料(Patient ClinEMR) | TW Core RelatedPerson)	誰以及/或什麼創建了文件
authenticator		0..1	Reference(健康照護服務提供人員資料(Practitioner ClinEMR) | TW Core PractitionerRole | 醫事機構(Organization ClinEMR))	誰/什麼對文件進行了認證
custodian		0..1	Reference(醫事機構(Organization ClinEMR))	維護此文件的機構
relatesTo
target		1..1	Reference(文件參照(DocumentReference ClinEMR))	存在此關係的目標文件
content		1..*	BackboneElement	被參照的文件。[應填入門診病摘之圖檔報告檔名或附件檔名(title)]
attachment	S	1..1	Attachment	存取文件的位置
Slices for extension				Content/Rules for all slices
position	S	0..1	CodeableConcept	[應填入牙醫診所門診病摘之圖檔報告牙位Image Position] URL: https://fhir.cohesiondata.com/clinemr/StructureDefinition/cohesion-position
contentType	S	1..1	code	【因FHIR必填】Mime type of the content, with charset etc.
data	S	1..1	base64Binary	資料之內容，必須轉成Base 64格式。
title		1..1	string	檔案名稱應包含副檔名。[應填入門診病摘之圖檔報告檔名Image File Name或附件檔名Reference Doc File Name]
context	S	0..1	BackboneElement	文件的臨床背景
encounter		0..*	Reference(就醫事件(Encounter ClinEMR))	文件內容的臨床背景
sourcePatientInfo		0..1	Reference(病人資料(Patient ClinEMR))	來源的病人人口統計資料
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	TWCoreDocumentReference	文件的參照
id	Σ	0..1	id	不重複的ID用以識別儲存在特定FHIR Server中的DocumentReference紀錄，通常又稱為邏輯性ID。
meta	Σ	0..1	Meta	此DocumentReference Resource的metadata
implicitRules	?!Σ	0..1	uri	創建此內容所依據的一組規則
language		0..1	code	用以表述DocumentReference Resource內容的語言。 Binding: CommonLanguages (preferred): 人類語言；鼓勵使用CommonLanguages代碼表中的代碼，但不強制一定要使用此代碼表，你也可使用其他代碼表的代碼或單純以文字表示。 Additional Bindings Purpose AllLanguages Max Binding Example Value: zh-TW
text		0..1	Narrative	DocumentReference Resource之內容摘要以供人閱讀
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
masterIdentifier	SΣ	0..1	Identifier	主版本的識別碼
identifier	Σ	0..*	Identifier	文件的其他的識別碼
status	?!SΣ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): 文件參照的狀態；應填入所綁定值集中的其中一個代碼。 Required Pattern: current
docStatus	Σ	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): 基礎文件的狀態；應填入所綁定值集中的其中一個代碼。
type	S	0..1	CodeableConceptTW	文件的類型（如果可能，使用 LOINC 代碼） Binding: LOINC Code Document Type值集 (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。
category	S	0..*	CodeableConceptTW	文件的類別 Binding: LOINC Document Class值集 (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。
subject	SΣ	1..1	Reference(病人資料(Patient ClinEMR))	文件描述的對象是誰/是什麼？
date	SΣ	0..1	instant	文件參照的創建時間是何時？
author	SΣ	0..*	Reference(健康照護服務提供人員資料(Practitioner ClinEMR) | TW Core PractitionerRole | 醫事機構(Organization ClinEMR) | TW Core Implantable Device | 病人資料(Patient ClinEMR) | TW Core RelatedPerson)	誰以及/或什麼創建了文件
authenticator		0..1	Reference(健康照護服務提供人員資料(Practitioner ClinEMR) | TW Core PractitionerRole | 醫事機構(Organization ClinEMR))	誰/什麼對文件進行了認證
custodian		0..1	Reference(醫事機構(Organization ClinEMR))	維護此文件的機構
relatesTo	Σ	0..*	BackboneElement	與其他文件的關係
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	Σ	1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): 文件之間的關係類型；應填入所綁定值集中的其中一個代碼。
target	Σ	1..1	Reference(文件參照(DocumentReference ClinEMR))	存在此關係的目標文件
description	Σ	0..1	string	人可讀的描述。
securityLabel		0..*	CodeableConceptTW	文件的安全標籤(security-tags) Binding: All Security Labels (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。
content	SΣ	1..*	BackboneElement	被參照的文件。[應填入門診病摘之圖檔報告檔名或附件檔名(title)]
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
attachment	SΣ	1..1	Attachment	存取文件的位置
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
position	S	0..1	CodeableConcept	[應填入牙醫診所門診病摘之圖檔報告牙位Image Position] URL: https://fhir.cohesiondata.com/clinemr/StructureDefinition/cohesion-position
contentType	SΣ	1..1	code	【因FHIR必填】Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
language	Σ	0..1	code	Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
data	S	1..1	base64Binary	資料之內容，必須轉成Base 64格式。
url	Σ	0..1	url	Uri where the data can be found Example General: http://www.acme.com/logo-small.png
size	Σ	0..1	unsignedInt	Number of bytes of content (if url provided)
hash	Σ	0..1	base64Binary	Hash of the data (sha-1, base64ed)
title	Σ	1..1	string	檔案名稱應包含副檔名。[應填入門診病摘之圖檔報告檔名Image File Name或附件檔名Reference Doc File Name] Example General: Official Corporate Logo
creation	Σ	0..1	dateTime	Date attachment was first created
format	Σ	0..1	Coding	文件的格式/內容規則。 Binding: DocumentReferenceFormatCodeSet (preferred): 鼓勵使用所綁定值集中的代碼，但不強制一定要使用此值集，你也可使用其他值集的代碼或單純以文字表示。
context	SΣ	0..1	BackboneElement	文件的臨床背景
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
encounter		0..*	Reference(就醫事件(Encounter ClinEMR))	文件內容的臨床背景
event		0..*	CodeableConceptTW	正在記錄的主要臨床行為 Binding: v3 Code System ActCode (example): 可參考所綁定值集，但此值集只是針對這個欄位的一個可能值的範例，不預期也不鼓勵使用者一定要使用此值集的代碼。
period	Σ	0..1	Period	被記錄的服務時間
facilityType		0..1	CodeableConcept	病人接受治療的機構類型 Binding: FacilityTypeCodeValueSet (example): 可參考所綁定值集，但此值集只是針對這個欄位的一個可能值的範例，不預期也不鼓勵使用者一定要使用此值集的代碼。
practiceSetting		0..1	CodeableConceptTW	內容創建的額外細節(例如：臨床專業) Binding: PracticeSettingCodeValueSet (example): 可參考所綁定值集，但此值集只是針對這個欄位的一個可能值的範例，不預期也不鼓勵使用者一定要使用此值集的代碼。
sourcePatientInfo		0..1	Reference(病人資料(Patient ClinEMR))	來源的病人人口統計資料
related		0..*	Reference(Resource)	相關的識別碼或resources
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
DocumentReference.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.status	required	Pattern: current http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard
DocumentReference.docStatus	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
DocumentReference.type	extensible	LOINCDocumentType https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-type-doc-code
DocumentReference.category	extensible	LOINCDocumentClass https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-document-classcodes
DocumentReference.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
DocumentReference.securityLabel	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13) http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard
DocumentReference.content.attachment.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.content.format	preferred	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem) http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard
DocumentReference.context.event	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet http://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet http://hl7.org/fhir/ValueSet/c80-practice-codes from the FHIR Standard

This structure is derived from TWCoreDocumentReference

Summary

Mandatory: 3 elements
Must-Support: 5 elements

Structures

This structure refers to these other structures:

• 病人資料(Patient ClinEMR) (https://fhir.cohesiondata.com/clinemr/StructureDefinition/patient-clinemr)
• 健康照護服務提供人員資料(Practitioner ClinEMR) (https://fhir.cohesiondata.com/clinemr/StructureDefinition/practitioner-clinemr)
• TW Core PractitionerRole (https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/PractitionerRole-twcore)
• 醫事機構(Organization ClinEMR) (https://fhir.cohesiondata.com/clinemr/StructureDefinition/organization-clinemr)
• TW Core Implantable Device (https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Device-twcore)
• TW Core RelatedPerson (https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/RelatedPerson-twcore)
• 文件參照(DocumentReference ClinEMR) (https://fhir.cohesiondata.com/clinemr/StructureDefinition/documentreference-clinemr)
• 就醫事件(Encounter ClinEMR) (https://fhir.cohesiondata.com/clinemr/StructureDefinition/encounter-clinemr)

Extensions

This structure refers to these extensions:

• https://fhir.cohesiondata.com/clinemr/StructureDefinition/cohesion-position

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	TWCoreDocumentReference	文件的參照 dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	創建此內容所依據的一組規則 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
masterIdentifier	SΣ	0..1	Identifier	主版本的識別碼 ele-1: All FHIR elements must have a @value or children
status	?!SΣ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): 文件參照的狀態；應填入所綁定值集中的其中一個代碼。 ele-1: All FHIR elements must have a @value or children Required Pattern: current
type	S	0..1	CodeableConceptTW	文件的類型（如果可能，使用 LOINC 代碼） Binding: LOINC Code Document Type值集 (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。 ele-1: All FHIR elements must have a @value or children
category	S	0..*	CodeableConceptTW	文件的類別 Binding: LOINC Document Class值集 (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。 ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(病人資料(Patient ClinEMR))	文件描述的對象是誰/是什麼？ ele-1: All FHIR elements must have a @value or children
date	SΣ	0..1	instant	文件參照的創建時間是何時？ ele-1: All FHIR elements must have a @value or children
author	SΣ	0..*	Reference(健康照護服務提供人員資料(Practitioner ClinEMR) | TW Core PractitionerRole | 醫事機構(Organization ClinEMR) | TW Core Implantable Device | 病人資料(Patient ClinEMR) | TW Core RelatedPerson)	誰以及/或什麼創建了文件 ele-1: All FHIR elements must have a @value or children
authenticator		0..1	Reference(健康照護服務提供人員資料(Practitioner ClinEMR) | TW Core PractitionerRole | 醫事機構(Organization ClinEMR))	誰/什麼對文件進行了認證 ele-1: All FHIR elements must have a @value or children
custodian		0..1	Reference(醫事機構(Organization ClinEMR))	維護此文件的機構 ele-1: All FHIR elements must have a @value or children
content	SΣ	1..*	BackboneElement	被參照的文件。[應填入門診病摘之圖檔報告檔名或附件檔名(title)] ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
attachment	SΣ	1..1	Attachment	存取文件的位置 ele-1: All FHIR elements must have a @value or children
Slices for extension				Content/Rules for all slices
position	S	0..1	CodeableConcept	[應填入牙醫診所門診病摘之圖檔報告牙位Image Position] URL: https://fhir.cohesiondata.com/clinemr/StructureDefinition/cohesion-position ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
contentType	SΣ	1..1	code	【因FHIR必填】Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. ele-1: All FHIR elements must have a @value or children Example General: text/plain; charset=UTF-8, image/png
data	S	1..1	base64Binary	資料之內容，必須轉成Base 64格式。 ele-1: All FHIR elements must have a @value or children
title	Σ	1..1	string	檔案名稱應包含副檔名。[應填入門診病摘之圖檔報告檔名Image File Name或附件檔名Reference Doc File Name] ele-1: All FHIR elements must have a @value or children Example General: Official Corporate Logo
context	SΣ	0..1	BackboneElement	文件的臨床背景 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
encounter		0..*	Reference(就醫事件(Encounter ClinEMR))	文件內容的臨床背景 ele-1: All FHIR elements must have a @value or children
sourcePatientInfo		0..1	Reference(病人資料(Patient ClinEMR))	來源的病人人口統計資料 ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
DocumentReference.status	required	Pattern: current http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard
DocumentReference.type	extensible	LOINCDocumentType https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-type-doc-code
DocumentReference.category	extensible	LOINCDocumentClass https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-document-classcodes
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13) http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard

Differential View

This structure is derived from TWCoreDocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference			TWCoreDocumentReference
status		1..1	code	current | superseded | entered-in-error Required Pattern: current
subject		1..1	Reference(病人資料(Patient ClinEMR))	文件描述的對象是誰/是什麼？
author		0..*	Reference(健康照護服務提供人員資料(Practitioner ClinEMR) | TW Core PractitionerRole | 醫事機構(Organization ClinEMR) | TW Core Implantable Device | 病人資料(Patient ClinEMR) | TW Core RelatedPerson)	誰以及/或什麼創建了文件
authenticator		0..1	Reference(健康照護服務提供人員資料(Practitioner ClinEMR) | TW Core PractitionerRole | 醫事機構(Organization ClinEMR))	誰/什麼對文件進行了認證
custodian		0..1	Reference(醫事機構(Organization ClinEMR))	維護此文件的機構
relatesTo
target		1..1	Reference(文件參照(DocumentReference ClinEMR))	存在此關係的目標文件
content		1..*	BackboneElement	被參照的文件。[應填入門診病摘之圖檔報告檔名或附件檔名(title)]
attachment	S	1..1	Attachment	存取文件的位置
Slices for extension				Content/Rules for all slices
position	S	0..1	CodeableConcept	[應填入牙醫診所門診病摘之圖檔報告牙位Image Position] URL: https://fhir.cohesiondata.com/clinemr/StructureDefinition/cohesion-position
contentType	S	1..1	code	【因FHIR必填】Mime type of the content, with charset etc.
data	S	1..1	base64Binary	資料之內容，必須轉成Base 64格式。
title		1..1	string	檔案名稱應包含副檔名。[應填入門診病摘之圖檔報告檔名Image File Name或附件檔名Reference Doc File Name]
context	S	0..1	BackboneElement	文件的臨床背景
encounter		0..*	Reference(就醫事件(Encounter ClinEMR))	文件內容的臨床背景
sourcePatientInfo		0..1	Reference(病人資料(Patient ClinEMR))	來源的病人人口統計資料
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	TWCoreDocumentReference	文件的參照
id	Σ	0..1	id	不重複的ID用以識別儲存在特定FHIR Server中的DocumentReference紀錄，通常又稱為邏輯性ID。
meta	Σ	0..1	Meta	此DocumentReference Resource的metadata
implicitRules	?!Σ	0..1	uri	創建此內容所依據的一組規則
language		0..1	code	用以表述DocumentReference Resource內容的語言。 Binding: CommonLanguages (preferred): 人類語言；鼓勵使用CommonLanguages代碼表中的代碼，但不強制一定要使用此代碼表，你也可使用其他代碼表的代碼或單純以文字表示。 Additional Bindings Purpose AllLanguages Max Binding Example Value: zh-TW
text		0..1	Narrative	DocumentReference Resource之內容摘要以供人閱讀
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
masterIdentifier	SΣ	0..1	Identifier	主版本的識別碼
identifier	Σ	0..*	Identifier	文件的其他的識別碼
status	?!SΣ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): 文件參照的狀態；應填入所綁定值集中的其中一個代碼。 Required Pattern: current
docStatus	Σ	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): 基礎文件的狀態；應填入所綁定值集中的其中一個代碼。
type	S	0..1	CodeableConceptTW	文件的類型（如果可能，使用 LOINC 代碼） Binding: LOINC Code Document Type值集 (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。
category	S	0..*	CodeableConceptTW	文件的類別 Binding: LOINC Document Class值集 (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。
subject	SΣ	1..1	Reference(病人資料(Patient ClinEMR))	文件描述的對象是誰/是什麼？
date	SΣ	0..1	instant	文件參照的創建時間是何時？
author	SΣ	0..*	Reference(健康照護服務提供人員資料(Practitioner ClinEMR) | TW Core PractitionerRole | 醫事機構(Organization ClinEMR) | TW Core Implantable Device | 病人資料(Patient ClinEMR) | TW Core RelatedPerson)	誰以及/或什麼創建了文件
authenticator		0..1	Reference(健康照護服務提供人員資料(Practitioner ClinEMR) | TW Core PractitionerRole | 醫事機構(Organization ClinEMR))	誰/什麼對文件進行了認證
custodian		0..1	Reference(醫事機構(Organization ClinEMR))	維護此文件的機構
relatesTo	Σ	0..*	BackboneElement	與其他文件的關係
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	Σ	1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): 文件之間的關係類型；應填入所綁定值集中的其中一個代碼。
target	Σ	1..1	Reference(文件參照(DocumentReference ClinEMR))	存在此關係的目標文件
description	Σ	0..1	string	人可讀的描述。
securityLabel		0..*	CodeableConceptTW	文件的安全標籤(security-tags) Binding: All Security Labels (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。
content	SΣ	1..*	BackboneElement	被參照的文件。[應填入門診病摘之圖檔報告檔名或附件檔名(title)]
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
attachment	SΣ	1..1	Attachment	存取文件的位置
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
position	S	0..1	CodeableConcept	[應填入牙醫診所門診病摘之圖檔報告牙位Image Position] URL: https://fhir.cohesiondata.com/clinemr/StructureDefinition/cohesion-position
contentType	SΣ	1..1	code	【因FHIR必填】Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
language	Σ	0..1	code	Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
data	S	1..1	base64Binary	資料之內容，必須轉成Base 64格式。
url	Σ	0..1	url	Uri where the data can be found Example General: http://www.acme.com/logo-small.png
size	Σ	0..1	unsignedInt	Number of bytes of content (if url provided)
hash	Σ	0..1	base64Binary	Hash of the data (sha-1, base64ed)
title	Σ	1..1	string	檔案名稱應包含副檔名。[應填入門診病摘之圖檔報告檔名Image File Name或附件檔名Reference Doc File Name] Example General: Official Corporate Logo
creation	Σ	0..1	dateTime	Date attachment was first created
format	Σ	0..1	Coding	文件的格式/內容規則。 Binding: DocumentReferenceFormatCodeSet (preferred): 鼓勵使用所綁定值集中的代碼，但不強制一定要使用此值集，你也可使用其他值集的代碼或單純以文字表示。
context	SΣ	0..1	BackboneElement	文件的臨床背景
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
encounter		0..*	Reference(就醫事件(Encounter ClinEMR))	文件內容的臨床背景
event		0..*	CodeableConceptTW	正在記錄的主要臨床行為 Binding: v3 Code System ActCode (example): 可參考所綁定值集，但此值集只是針對這個欄位的一個可能值的範例，不預期也不鼓勵使用者一定要使用此值集的代碼。
period	Σ	0..1	Period	被記錄的服務時間
facilityType		0..1	CodeableConcept	病人接受治療的機構類型 Binding: FacilityTypeCodeValueSet (example): 可參考所綁定值集，但此值集只是針對這個欄位的一個可能值的範例，不預期也不鼓勵使用者一定要使用此值集的代碼。
practiceSetting		0..1	CodeableConceptTW	內容創建的額外細節(例如：臨床專業) Binding: PracticeSettingCodeValueSet (example): 可參考所綁定值集，但此值集只是針對這個欄位的一個可能值的範例，不預期也不鼓勵使用者一定要使用此值集的代碼。
sourcePatientInfo		0..1	Reference(病人資料(Patient ClinEMR))	來源的病人人口統計資料
related		0..*	Reference(Resource)	相關的識別碼或resources
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
DocumentReference.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.status	required	Pattern: current http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard
DocumentReference.docStatus	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
DocumentReference.type	extensible	LOINCDocumentType https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-type-doc-code
DocumentReference.category	extensible	LOINCDocumentClass https://twcore.mohw.gov.tw/ig/twcore/ValueSet/loinc-document-classcodes
DocumentReference.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
DocumentReference.securityLabel	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13) http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard
DocumentReference.content.attachment.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.content.format	preferred	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem) http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard
DocumentReference.context.event	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet http://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet http://hl7.org/fhir/ValueSet/c80-practice-codes from the FHIR Standard

This structure is derived from TWCoreDocumentReference

Summary

Mandatory: 3 elements
Must-Support: 5 elements

Structures

This structure refers to these other structures:

• 病人資料(Patient ClinEMR) (https://fhir.cohesiondata.com/clinemr/StructureDefinition/patient-clinemr)
• 健康照護服務提供人員資料(Practitioner ClinEMR) (https://fhir.cohesiondata.com/clinemr/StructureDefinition/practitioner-clinemr)
• TW Core PractitionerRole (https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/PractitionerRole-twcore)
• 醫事機構(Organization ClinEMR) (https://fhir.cohesiondata.com/clinemr/StructureDefinition/organization-clinemr)
• TW Core Implantable Device (https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Device-twcore)
• TW Core RelatedPerson (https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/RelatedPerson-twcore)
• 文件參照(DocumentReference ClinEMR) (https://fhir.cohesiondata.com/clinemr/StructureDefinition/documentreference-clinemr)
• 就醫事件(Encounter ClinEMR) (https://fhir.cohesiondata.com/clinemr/StructureDefinition/encounter-clinemr)

Extensions

This structure refers to these extensions:

• https://fhir.cohesiondata.com/clinemr/StructureDefinition/cohesion-position

Other representations of profile: CSV, Excel, Schematron