診所門診病摘實作指引
1.0.1 - CI Build

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

Resource Profile: 就醫事件(Encounter ClinEMR)

Official URL: https://fhir.cohesiondata.com/clinemr/StructureDefinition/encounter-clinemr Version: 1.0.1
Active as of 2025-02-06 Computable Name: EncounterClinEMR

此就醫事件(Encounter ClinEMR)Profile說明本IG如何進一步定義臺灣核心-就醫事件(TW Core Encounter) Profile以呈現西醫/牙醫/中醫診所門診病摘之就醫事件的詳細資料。

Usage:

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 0..* TWCoreEncounter 提供病人服務的一種互動
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
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... medicalIdentity S 1..1 CodeableConcept 就醫身份
URL: https://fhir.cohesiondata.com/clinemr/StructureDefinition/cohesion-medicalidentity
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... 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
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (如果知道)
Binding: IdentifierUse (required): 如果知道,請說明此識別碼的用途;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
.... type S 1..1 CodeableConceptTW 識別碼(identifier)的型別說明
Binding: Identifier Type Codes (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
Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: SNO
.... system SΣ 1..1 uri 識別碼(identifier)的命名空間(namespace)
ele-1: All FHIR elements must have a @value or children
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string 唯一值。[應填入門診病摘之掛號序號Visit Seq]
ele-1: All FHIR elements must have a @value or children
Example General: 123456
... status ?!SΣ 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): 就醫現況的代碼;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: finished
... class S 1..1 CodingTW 病人就醫的分類
Binding: ActEncounterCode (extensible): 就醫的分類;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
Required Pattern: At least the following
.... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
.... code 1..1 code Symbol in syntax defined by the system
Fixed Value: AMB
... serviceType S 1..1 CodeableConceptTW 服務的特定型別。[應填入門診病摘之看診科別Dpartment]
Binding: ServiceType (example): 對提供的服務進行廣泛分類;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
.... Slices for coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼
Slice: Unordered, Open by pattern:system
ele-1: All FHIR elements must have a @value or children
..... coding:TWMedicalDepartmentSCT S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 對應至 SNOMED CT之就醫科別 + 診療科別值集 (required)
ele-1: All FHIR elements must have a @value or children
...... system SΣ 1..1 uri 專門術語系統(terminology system)的識別
ele-1: All FHIR elements must have a @value or children
Required Pattern: http://snomed.info/sct
...... code SΣ 0..1 code 系統定義的語法之符號
ele-1: All FHIR elements must have a @value or children
...... display SΣ 0..1 string 由系統定義的表示法
ele-1: All FHIR elements must have a @value or children
..... coding:TWMedicalConsultationDepartment S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 無法對應至SNOMED CT之臺灣健保署就醫科別值集 (required)
ele-1: All FHIR elements must have a @value or children
...... system SΣ 1..1 uri 專門術語系統(terminology system)的識別
ele-1: All FHIR elements must have a @value or children
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-consultation-department-nhi-tw
...... code SΣ 0..1 code 系統定義的語法之符號
ele-1: All FHIR elements must have a @value or children
...... display SΣ 0..1 string 由系統定義的表示法
ele-1: All FHIR elements must have a @value or children
..... coding:TWMedicalTreatmentDepartment S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 無法對應至SNOMED CT之臺灣健保署診療科別值集 (required)
ele-1: All FHIR elements must have a @value or children
...... system SΣ 1..1 uri 專門術語系統(terminology system)的識別
ele-1: All FHIR elements must have a @value or children
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-treatment-department-nhi-tw
...... code SΣ 0..1 code 系統定義的語法之符號
ele-1: All FHIR elements must have a @value or children
...... display SΣ 0..1 string 由系統定義的表示法
ele-1: All FHIR elements must have a @value or children
.... text SΣ 0..1 string 概念的文字表示法
ele-1: All FHIR elements must have a @value or children
... subject SΣ 0..1 Reference(病人資料(Patient ClinEMR)) 在場就醫的病人或實體集合(Group)
ele-1: All FHIR elements must have a @value or children
... basedOn 0..* Reference(服務請求(ServiceRequest ClinEMR)) 開始此次就醫的服務請求(ServiceRequest)
ele-1: All FHIR elements must have a @value or children
... participant SΣ 0..* BackboneElement 參與就醫的健康照護服務提供者之名單
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
.... type S 0..* CodeableConceptTW 參與者在病人就醫事件中的角色
Binding: ParticipantType (extensible): 參與者在病人就醫事件中的角色;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
.... period S 0..1 Period 參與者在病人就醫期間參與的時段
ele-1: All FHIR elements must have a @value or children
.... individual SΣ 0..1 Reference(健康照護服務提供人員資料(Practitioner ClinEMR) | TW Core PractitionerRole | TW Core RelatedPerson) 除病人外,參與病人就醫事件的人。
ele-1: All FHIR elements must have a @value or children
... period S 1..1 Period 就醫的開始和結束時間
ele-1: All FHIR elements must have a @value or children
.... start SΣC 1..1 dateTime 就醫的開始時間。[應填入門診病摘之掛號(報到)日期時間Visit Date]
ele-1: All FHIR elements must have a @value or children
... reasonCode S 0..* CodeableConceptTW 就醫發生的編碼原因
Binding: EncounterReasonCodes (preferred): 發生此就醫事件的原因;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。


ele-1: All FHIR elements must have a @value or children
... reasonReference Σ 0..* Reference(病情、問題或診斷(ConditionDiagnosis ClinEMR) | 西醫-處置或手術(Procedure MCR) | 檢驗檢查(Observation ClinEMR) | ImmunizationRecommendation) 就醫發生的原因(參照)
ele-1: All FHIR elements must have a @value or children
... hospitalization S 0..1 BackboneElement 關於入院接受健康照護服務的細節
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
.... origin 0..1 Reference(醫事機構(Organization ClinEMR) | TW Core Location) 病人住院前來自的地點/機構
ele-1: All FHIR elements must have a @value or children
.... destination 0..1 Reference(TW Core Location | 醫事機構(Organization ClinEMR)) 病人出院地點/機構
ele-1: All FHIR elements must have a @value or children
.... dischargeDisposition S 0..1 CodeableConceptTW 出院後的地點類別或種類
Binding: DischargeDisposition (example): 出院處置;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。


ele-1: All FHIR elements must have a @value or children
... location S 0..* BackboneElement 病人曾去過的一個或多個地點
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
.... location S 1..1 Reference(TW Core Location) 就醫發生的地點
ele-1: All FHIR elements must have a @value or children
... serviceProvider S 0..1 Reference(醫事機構(Organization ClinEMR)) 負責這次就醫的機構
ele-1: All FHIR elements must have a @value or children
... partOf 0..1 Reference(就醫事件(Encounter ClinEMR)) 此就醫是哪次就醫的一部份?
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Encounter.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Encounter.identifier.typeextensiblePattern: SNO
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Encounter.statusrequiredPattern: finished
http://hl7.org/fhir/ValueSet/encounter-status|4.0.1
from the FHIR Standard
Encounter.classextensiblePattern: AMB
http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
Encounter.serviceTypeexampleServiceType
http://hl7.org/fhir/ValueSet/service-type
from the FHIR Standard
Encounter.serviceType.coding:TWMedicalDepartmentSCTrequiredTWMedicalDepartmentSCT
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/medical-department-sct-tw
Encounter.serviceType.coding:TWMedicalConsultationDepartmentrequiredTWMedicalConsultationDepartment
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/medical-consultation-department-tw
Encounter.serviceType.coding:TWMedicalTreatmentDepartmentrequiredTWMedicalTreatmentDepartment
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/medical-treatment-department-tw
Encounter.participant.typeextensibleParticipantType
http://hl7.org/fhir/ValueSet/encounter-participant-type
from the FHIR Standard
Encounter.reasonCodepreferredEncounterReasonCodes
http://hl7.org/fhir/ValueSet/encounter-reason
from the FHIR Standard
Encounter.hospitalization.dischargeDispositionexampleDischargeDisposition
http://hl7.org/fhir/ValueSet/encounter-discharge-disposition
from the FHIR Standard

This structure is derived from TWCoreEncounter

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter TWCoreEncounter
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... medicalIdentity S 1..1 CodeableConcept 就醫身份
URL: https://fhir.cohesiondata.com/clinemr/StructureDefinition/cohesion-medicalidentity
... identifier 1..1 Identifier 此就醫事件的識別碼
.... type S 1..1 CodeableConceptTW 識別碼(identifier)的型別說明
Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: SNO
.... value 1..1 string 唯一值。[應填入門診病摘之掛號序號Visit Seq]
... status 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
Required Pattern: finished
.... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
.... code 1..1 code Symbol in syntax defined by the system
Fixed Value: AMB
... serviceType 1..1 CodeableConceptTW 服務的特定型別。[應填入門診病摘之看診科別Dpartment]
... subject 0..1 Reference(病人資料(Patient ClinEMR)) 在場就醫的病人或實體集合(Group)
... basedOn 0..* Reference(服務請求(ServiceRequest ClinEMR)) 開始此次就醫的服務請求(ServiceRequest)
... participant
.... individual 0..1 Reference(健康照護服務提供人員資料(Practitioner ClinEMR) | TW Core PractitionerRole | TW Core RelatedPerson) 除病人外,參與病人就醫事件的人。
... period 1..1 Period 就醫的開始和結束時間
.... start S 1..1 dateTime 就醫的開始時間。[應填入門診病摘之掛號(報到)日期時間Visit Date]
... reasonReference 0..* Reference(病情、問題或診斷(ConditionDiagnosis ClinEMR) | 西醫-處置或手術(Procedure MCR) | 檢驗檢查(Observation ClinEMR) | ImmunizationRecommendation) 就醫發生的原因(參照)
... diagnosis
.... condition 1..1 Reference(病情、問題或診斷(ConditionDiagnosis ClinEMR)) 與就醫事件相關的診斷或處置
... hospitalization
.... origin 0..1 Reference(醫事機構(Organization ClinEMR) | TW Core Location) 病人住院前來自的地點/機構
.... destination 0..1 Reference(TW Core Location | 醫事機構(Organization ClinEMR)) 病人出院地點/機構
... serviceProvider 0..1 Reference(醫事機構(Organization ClinEMR)) 負責這次就醫的機構
... partOf 0..1 Reference(就醫事件(Encounter ClinEMR)) 此就醫是哪次就醫的一部份?

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 0..* TWCoreEncounter 提供病人服務的一種互動
... id Σ 0..1 id 不重複的ID用以識別儲存在特定FHIR Server中的Encounter紀錄,通常又稱為邏輯性ID。
... meta Σ 0..1 Meta 此Encounter 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Encounter 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 BindingsPurpose
AllLanguages Max Binding

Example Value: zh-TW
... text 0..1 Narrative Encounter Resource之內容摘要以供人閱讀
... contained 0..* Resource Contained, inline Resources
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... medicalIdentity S 1..1 CodeableConcept 就醫身份
URL: https://fhir.cohesiondata.com/clinemr/StructureDefinition/cohesion-medicalidentity
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier 此就醫事件的識別碼
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (如果知道)
Binding: IdentifierUse (required): 如果知道,請說明此識別碼的用途;應填入所綁定值集中的其中一個代碼。

.... type S 1..1 CodeableConceptTW 識別碼(identifier)的型別說明
Binding: Identifier Type Codes (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。


Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: SNO
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
.... system SΣ 1..1 uri 識別碼(identifier)的命名空間(namespace)
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string 唯一值。[應填入門診病摘之掛號序號Visit Seq]
Example General: 123456
.... period Σ 0..1 Period 此就醫事件識別碼(identifier)的使用效期
.... assigner Σ 0..1 Reference(TW Core Organization) 簽發identifier的機構(可以只是文字表述)
... status ?!SΣ 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): 就醫現況的代碼;應填入所綁定值集中的其中一個代碼


Required Pattern: finished
... statusHistory 0..* BackboneElement 過去的就醫狀態清單
.... 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
.... status 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): 就醫現狀的代碼;應填入所綁定值集中的其中一個代碼

.... period 1..1 Period 該事件處於特定狀態的時間
... class S 1..1 CodingTW 病人就醫的分類
Binding: ActEncounterCode (extensible): 就醫的分類;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。


Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
.... version 0..1 string Version of the system - if relevant
.... code 1..1 code Symbol in syntax defined by the system
Fixed Value: AMB
.... display 0..1 string Representation defined by the system
.... userSelected 0..1 boolean If this coding was chosen directly by the user
... classHistory 0..* BackboneElement 過去就醫類別的列表
.... 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
.... class 1..1 Coding inpatient | outpatient | ambulatory | emergency +
Binding: ActEncounterCode (extensible): 就醫類別;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。

.... period 1..1 Period 此就醫事件處於特定類別的時間
... type 0..* CodeableConceptTW 就醫的特定型別
Binding: EncounterType (example): 就醫的型別;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。


... serviceType S 1..1 CodeableConceptTW 服務的特定型別。[應填入門診病摘之看診科別Dpartment]
Binding: ServiceType (example): 對提供的服務進行廣泛分類;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。

.... 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
Slice: Unordered, Open by pattern:system
..... coding:TWMedicalDepartmentSCT S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 對應至 SNOMED CT之就醫科別 + 診療科別值集 (required)
...... 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
...... system SΣ 1..1 uri 專門術語系統(terminology system)的識別
Required Pattern: http://snomed.info/sct
...... version Σ 0..1 string 系統的版本—如果相關的話
...... code SΣ 0..1 code 系統定義的語法之符號
...... display SΣ 0..1 string 由系統定義的表示法
...... userSelected Σ 0..1 boolean 此編碼是否由使用者直接選擇?
..... coding:TWMedicalConsultationDepartment S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 無法對應至SNOMED CT之臺灣健保署就醫科別值集 (required)
...... 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
...... system SΣ 1..1 uri 專門術語系統(terminology system)的識別
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-consultation-department-nhi-tw
...... version Σ 0..1 string 系統的版本—如果相關的話
...... code SΣ 0..1 code 系統定義的語法之符號
...... display SΣ 0..1 string 由系統定義的表示法
...... userSelected Σ 0..1 boolean 此編碼是否由使用者直接選擇?
..... coding:TWMedicalTreatmentDepartment S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 無法對應至SNOMED CT之臺灣健保署診療科別值集 (required)
...... 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
...... system SΣ 1..1 uri 專門術語系統(terminology system)的識別
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-treatment-department-nhi-tw
...... version Σ 0..1 string 系統的版本—如果相關的話
...... code SΣ 0..1 code 系統定義的語法之符號
...... display SΣ 0..1 string 由系統定義的表示法
...... userSelected Σ 0..1 boolean 此編碼是否由使用者直接選擇?
.... text SΣ 0..1 string 概念的文字表示法
... priority 0..1 CodeableConceptTW 表明就醫的急迫性
Binding: ActPriority (example): 表明就醫的迫切性;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。

... subject SΣ 0..1 Reference(病人資料(Patient ClinEMR)) 在場就醫的病人或實體集合(Group)
... episodeOfCare Σ 0..* Reference(EpisodeOfCare) 此次就醫應記錄的照護事件
... basedOn 0..* Reference(服務請求(ServiceRequest ClinEMR)) 開始此次就醫的服務請求(ServiceRequest)
... participant SΣ 0..* BackboneElement 參與就醫的健康照護服務提供者之名單
.... 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
.... type S 0..* CodeableConceptTW 參與者在病人就醫事件中的角色
Binding: ParticipantType (extensible): 參與者在病人就醫事件中的角色;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。


.... period S 0..1 Period 參與者在病人就醫期間參與的時段
.... individual SΣ 0..1 Reference(健康照護服務提供人員資料(Practitioner ClinEMR) | TW Core PractitionerRole | TW Core RelatedPerson) 除病人外,參與病人就醫事件的人。
... appointment Σ 0..* Reference(Appointment) 這次就醫的預約紀錄
... period S 1..1 Period 就醫的開始和結束時間
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... start SΣC 1..1 dateTime 就醫的開始時間。[應填入門診病摘之掛號(報到)日期時間Visit Date]
.... end ΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... length 0..1 Duration 就醫持續的時間(扣除缺席時間)
... reasonCode S 0..* CodeableConceptTW 就醫發生的編碼原因
Binding: EncounterReasonCodes (preferred): 發生此就醫事件的原因;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。


... reasonReference Σ 0..* Reference(病情、問題或診斷(ConditionDiagnosis ClinEMR) | 西醫-處置或手術(Procedure MCR) | 檢驗檢查(Observation ClinEMR) | ImmunizationRecommendation) 就醫發生的原因(參照)
... diagnosis Σ 0..* BackboneElement 與此就醫相關的診斷清單
.... 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
.... condition Σ 1..1 Reference(病情、問題或診斷(ConditionDiagnosis ClinEMR)) 與就醫事件相關的診斷或處置
.... use 0..1 CodeableConceptTW 此診斷在病人就醫事件中的作用(例如:住院、收費、出院...)。
Binding: DiagnosisRole (preferred): 此情況所代表的診斷型別;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。

.... rank 0..1 positiveInt 診斷的排序(針對每個角色型別)
... account 0..* Reference(Account) 可用於為此病人就醫事件計費的一組帳戶
... hospitalization S 0..1 BackboneElement 關於入院接受健康照護服務的細節
.... 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
.... preAdmissionIdentifier 0..1 Identifier 住院前識別碼
.... origin 0..1 Reference(醫事機構(Organization ClinEMR) | TW Core Location) 病人住院前來自的地點/機構
.... admitSource 0..1 CodeableConceptTW 病人從哪裡住院(醫生轉介、轉院)?
Binding: AdmitSource (preferred): 病人從哪裡住院;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。

.... reAdmission 0..1 CodeableConceptTW 已發生的醫院再入院型別(如果有的話)。如果該值不存在,則不被認定為再入院。
Binding: hl7VS-re-admissionIndicator (example): 這次住院就醫的再入院原因;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。

.... dietPreference 0..* CodeableConceptTW 病人報告的飲食偏好
Binding: Diet (example): 醫療、文化或道德方面的食物偏好,以幫助滿足飲食要求;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。


.... specialCourtesy 0..* CodeableConceptTW 特別禮遇(貴賓、董事會成員)
Binding: SpecialCourtesy (preferred): 特別禮遇;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。


.... specialArrangement 0..* CodeableConceptTW 輪椅、翻譯人員、擔架等。
Binding: SpecialArrangements (preferred): 特殊安排;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。


.... destination 0..1 Reference(TW Core Location | 醫事機構(Organization ClinEMR)) 病人出院地點/機構
.... dischargeDisposition S 0..1 CodeableConceptTW 出院後的地點類別或種類
Binding: DischargeDisposition (example): 出院處置;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。

... location S 0..* BackboneElement 病人曾去過的一個或多個地點
.... 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
.... location S 1..1 Reference(TW Core Location) 就醫發生的地點
.... status 0..1 code planned | active | reserved | completed
Binding: EncounterLocationStatus (required): 就醫地點的狀態;應填入所綁定值集中的其中一個代碼。

.... physicalType 0..1 CodeableConceptTW 地點的實體型別(通常是地點的層級—床位、房間、病房等)。
Binding: LocationType (example): 地點的實體型別;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 0..1 Period 病人出現在此地點的時段
... serviceProvider S 0..1 Reference(醫事機構(Organization ClinEMR)) 負責這次就醫的機構
... partOf 0..1 Reference(就醫事件(Encounter ClinEMR)) 此就醫是哪次就醫的一部份?

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Encounter.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Encounter.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Encounter.identifier.typeextensiblePattern: SNO
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Encounter.statusrequiredPattern: finished
http://hl7.org/fhir/ValueSet/encounter-status|4.0.1
from the FHIR Standard
Encounter.statusHistory.statusrequiredEncounterStatus
http://hl7.org/fhir/ValueSet/encounter-status|4.0.1
from the FHIR Standard
Encounter.classextensiblePattern: AMB
http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
Encounter.classHistory.classextensibleActEncounterCode
http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
Encounter.typeexampleEncounterType
http://hl7.org/fhir/ValueSet/encounter-type
from the FHIR Standard
Encounter.serviceTypeexampleServiceType
http://hl7.org/fhir/ValueSet/service-type
from the FHIR Standard
Encounter.serviceType.coding:TWMedicalDepartmentSCTrequiredTWMedicalDepartmentSCT
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/medical-department-sct-tw
Encounter.serviceType.coding:TWMedicalConsultationDepartmentrequiredTWMedicalConsultationDepartment
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/medical-consultation-department-tw
Encounter.serviceType.coding:TWMedicalTreatmentDepartmentrequiredTWMedicalTreatmentDepartment
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/medical-treatment-department-tw
Encounter.priorityexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Encounter.participant.typeextensibleParticipantType
http://hl7.org/fhir/ValueSet/encounter-participant-type
from the FHIR Standard
Encounter.reasonCodepreferredEncounterReasonCodes
http://hl7.org/fhir/ValueSet/encounter-reason
from the FHIR Standard
Encounter.diagnosis.usepreferredDiagnosisRole
http://hl7.org/fhir/ValueSet/diagnosis-role
from the FHIR Standard
Encounter.hospitalization.admitSourcepreferredAdmitSource
http://hl7.org/fhir/ValueSet/encounter-admit-source
from the FHIR Standard
Encounter.hospitalization.reAdmissionexampleHl7VSReAdmissionIndicator
http://terminology.hl7.org/ValueSet/v2-0092
Encounter.hospitalization.dietPreferenceexampleDiet
http://hl7.org/fhir/ValueSet/encounter-diet
from the FHIR Standard
Encounter.hospitalization.specialCourtesypreferredSpecialCourtesy
http://hl7.org/fhir/ValueSet/encounter-special-courtesy
from the FHIR Standard
Encounter.hospitalization.specialArrangementpreferredSpecialArrangements
http://hl7.org/fhir/ValueSet/encounter-special-arrangements
from the FHIR Standard
Encounter.hospitalization.dischargeDispositionexampleDischargeDisposition
http://hl7.org/fhir/ValueSet/encounter-discharge-disposition
from the FHIR Standard
Encounter.location.statusrequiredEncounterLocationStatus
http://hl7.org/fhir/ValueSet/encounter-location-status|4.0.1
from the FHIR Standard
Encounter.location.physicalTypeexampleLocationType
http://hl7.org/fhir/ValueSet/location-physical-type
from the FHIR Standard

This structure is derived from TWCoreEncounter

Summary

Mandatory: 7 elements
Must-Support: 3 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 0..* TWCoreEncounter 提供病人服務的一種互動
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
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... medicalIdentity S 1..1 CodeableConcept 就醫身份
URL: https://fhir.cohesiondata.com/clinemr/StructureDefinition/cohesion-medicalidentity
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... 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
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (如果知道)
Binding: IdentifierUse (required): 如果知道,請說明此識別碼的用途;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
.... type S 1..1 CodeableConceptTW 識別碼(identifier)的型別說明
Binding: Identifier Type Codes (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
Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: SNO
.... system SΣ 1..1 uri 識別碼(identifier)的命名空間(namespace)
ele-1: All FHIR elements must have a @value or children
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string 唯一值。[應填入門診病摘之掛號序號Visit Seq]
ele-1: All FHIR elements must have a @value or children
Example General: 123456
... status ?!SΣ 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): 就醫現況的代碼;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: finished
... class S 1..1 CodingTW 病人就醫的分類
Binding: ActEncounterCode (extensible): 就醫的分類;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
Required Pattern: At least the following
.... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
.... code 1..1 code Symbol in syntax defined by the system
Fixed Value: AMB
... serviceType S 1..1 CodeableConceptTW 服務的特定型別。[應填入門診病摘之看診科別Dpartment]
Binding: ServiceType (example): 對提供的服務進行廣泛分類;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
.... Slices for coding S 0..* CodingTW 由專門術語系統(terminology system)定義的代碼
Slice: Unordered, Open by pattern:system
ele-1: All FHIR elements must have a @value or children
..... coding:TWMedicalDepartmentSCT S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 對應至 SNOMED CT之就醫科別 + 診療科別值集 (required)
ele-1: All FHIR elements must have a @value or children
...... system SΣ 1..1 uri 專門術語系統(terminology system)的識別
ele-1: All FHIR elements must have a @value or children
Required Pattern: http://snomed.info/sct
...... code SΣ 0..1 code 系統定義的語法之符號
ele-1: All FHIR elements must have a @value or children
...... display SΣ 0..1 string 由系統定義的表示法
ele-1: All FHIR elements must have a @value or children
..... coding:TWMedicalConsultationDepartment S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 無法對應至SNOMED CT之臺灣健保署就醫科別值集 (required)
ele-1: All FHIR elements must have a @value or children
...... system SΣ 1..1 uri 專門術語系統(terminology system)的識別
ele-1: All FHIR elements must have a @value or children
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-consultation-department-nhi-tw
...... code SΣ 0..1 code 系統定義的語法之符號
ele-1: All FHIR elements must have a @value or children
...... display SΣ 0..1 string 由系統定義的表示法
ele-1: All FHIR elements must have a @value or children
..... coding:TWMedicalTreatmentDepartment S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 無法對應至SNOMED CT之臺灣健保署診療科別值集 (required)
ele-1: All FHIR elements must have a @value or children
...... system SΣ 1..1 uri 專門術語系統(terminology system)的識別
ele-1: All FHIR elements must have a @value or children
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-treatment-department-nhi-tw
...... code SΣ 0..1 code 系統定義的語法之符號
ele-1: All FHIR elements must have a @value or children
...... display SΣ 0..1 string 由系統定義的表示法
ele-1: All FHIR elements must have a @value or children
.... text SΣ 0..1 string 概念的文字表示法
ele-1: All FHIR elements must have a @value or children
... subject SΣ 0..1 Reference(病人資料(Patient ClinEMR)) 在場就醫的病人或實體集合(Group)
ele-1: All FHIR elements must have a @value or children
... basedOn 0..* Reference(服務請求(ServiceRequest ClinEMR)) 開始此次就醫的服務請求(ServiceRequest)
ele-1: All FHIR elements must have a @value or children
... participant SΣ 0..* BackboneElement 參與就醫的健康照護服務提供者之名單
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
.... type S 0..* CodeableConceptTW 參與者在病人就醫事件中的角色
Binding: ParticipantType (extensible): 參與者在病人就醫事件中的角色;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
.... period S 0..1 Period 參與者在病人就醫期間參與的時段
ele-1: All FHIR elements must have a @value or children
.... individual SΣ 0..1 Reference(健康照護服務提供人員資料(Practitioner ClinEMR) | TW Core PractitionerRole | TW Core RelatedPerson) 除病人外,參與病人就醫事件的人。
ele-1: All FHIR elements must have a @value or children
... period S 1..1 Period 就醫的開始和結束時間
ele-1: All FHIR elements must have a @value or children
.... start SΣC 1..1 dateTime 就醫的開始時間。[應填入門診病摘之掛號(報到)日期時間Visit Date]
ele-1: All FHIR elements must have a @value or children
... reasonCode S 0..* CodeableConceptTW 就醫發生的編碼原因
Binding: EncounterReasonCodes (preferred): 發生此就醫事件的原因;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。


ele-1: All FHIR elements must have a @value or children
... reasonReference Σ 0..* Reference(病情、問題或診斷(ConditionDiagnosis ClinEMR) | 西醫-處置或手術(Procedure MCR) | 檢驗檢查(Observation ClinEMR) | ImmunizationRecommendation) 就醫發生的原因(參照)
ele-1: All FHIR elements must have a @value or children
... hospitalization S 0..1 BackboneElement 關於入院接受健康照護服務的細節
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
.... origin 0..1 Reference(醫事機構(Organization ClinEMR) | TW Core Location) 病人住院前來自的地點/機構
ele-1: All FHIR elements must have a @value or children
.... destination 0..1 Reference(TW Core Location | 醫事機構(Organization ClinEMR)) 病人出院地點/機構
ele-1: All FHIR elements must have a @value or children
.... dischargeDisposition S 0..1 CodeableConceptTW 出院後的地點類別或種類
Binding: DischargeDisposition (example): 出院處置;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。


ele-1: All FHIR elements must have a @value or children
... location S 0..* BackboneElement 病人曾去過的一個或多個地點
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
.... location S 1..1 Reference(TW Core Location) 就醫發生的地點
ele-1: All FHIR elements must have a @value or children
... serviceProvider S 0..1 Reference(醫事機構(Organization ClinEMR)) 負責這次就醫的機構
ele-1: All FHIR elements must have a @value or children
... partOf 0..1 Reference(就醫事件(Encounter ClinEMR)) 此就醫是哪次就醫的一部份?
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Encounter.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Encounter.identifier.typeextensiblePattern: SNO
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Encounter.statusrequiredPattern: finished
http://hl7.org/fhir/ValueSet/encounter-status|4.0.1
from the FHIR Standard
Encounter.classextensiblePattern: AMB
http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
Encounter.serviceTypeexampleServiceType
http://hl7.org/fhir/ValueSet/service-type
from the FHIR Standard
Encounter.serviceType.coding:TWMedicalDepartmentSCTrequiredTWMedicalDepartmentSCT
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/medical-department-sct-tw
Encounter.serviceType.coding:TWMedicalConsultationDepartmentrequiredTWMedicalConsultationDepartment
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/medical-consultation-department-tw
Encounter.serviceType.coding:TWMedicalTreatmentDepartmentrequiredTWMedicalTreatmentDepartment
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/medical-treatment-department-tw
Encounter.participant.typeextensibleParticipantType
http://hl7.org/fhir/ValueSet/encounter-participant-type
from the FHIR Standard
Encounter.reasonCodepreferredEncounterReasonCodes
http://hl7.org/fhir/ValueSet/encounter-reason
from the FHIR Standard
Encounter.hospitalization.dischargeDispositionexampleDischargeDisposition
http://hl7.org/fhir/ValueSet/encounter-discharge-disposition
from the FHIR Standard

Differential View

This structure is derived from TWCoreEncounter

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter TWCoreEncounter
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... medicalIdentity S 1..1 CodeableConcept 就醫身份
URL: https://fhir.cohesiondata.com/clinemr/StructureDefinition/cohesion-medicalidentity
... identifier 1..1 Identifier 此就醫事件的識別碼
.... type S 1..1 CodeableConceptTW 識別碼(identifier)的型別說明
Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: SNO
.... value 1..1 string 唯一值。[應填入門診病摘之掛號序號Visit Seq]
... status 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
Required Pattern: finished
.... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
.... code 1..1 code Symbol in syntax defined by the system
Fixed Value: AMB
... serviceType 1..1 CodeableConceptTW 服務的特定型別。[應填入門診病摘之看診科別Dpartment]
... subject 0..1 Reference(病人資料(Patient ClinEMR)) 在場就醫的病人或實體集合(Group)
... basedOn 0..* Reference(服務請求(ServiceRequest ClinEMR)) 開始此次就醫的服務請求(ServiceRequest)
... participant
.... individual 0..1 Reference(健康照護服務提供人員資料(Practitioner ClinEMR) | TW Core PractitionerRole | TW Core RelatedPerson) 除病人外,參與病人就醫事件的人。
... period 1..1 Period 就醫的開始和結束時間
.... start S 1..1 dateTime 就醫的開始時間。[應填入門診病摘之掛號(報到)日期時間Visit Date]
... reasonReference 0..* Reference(病情、問題或診斷(ConditionDiagnosis ClinEMR) | 西醫-處置或手術(Procedure MCR) | 檢驗檢查(Observation ClinEMR) | ImmunizationRecommendation) 就醫發生的原因(參照)
... diagnosis
.... condition 1..1 Reference(病情、問題或診斷(ConditionDiagnosis ClinEMR)) 與就醫事件相關的診斷或處置
... hospitalization
.... origin 0..1 Reference(醫事機構(Organization ClinEMR) | TW Core Location) 病人住院前來自的地點/機構
.... destination 0..1 Reference(TW Core Location | 醫事機構(Organization ClinEMR)) 病人出院地點/機構
... serviceProvider 0..1 Reference(醫事機構(Organization ClinEMR)) 負責這次就醫的機構
... partOf 0..1 Reference(就醫事件(Encounter ClinEMR)) 此就醫是哪次就醫的一部份?

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 0..* TWCoreEncounter 提供病人服務的一種互動
... id Σ 0..1 id 不重複的ID用以識別儲存在特定FHIR Server中的Encounter紀錄,通常又稱為邏輯性ID。
... meta Σ 0..1 Meta 此Encounter 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Encounter 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 BindingsPurpose
AllLanguages Max Binding

Example Value: zh-TW
... text 0..1 Narrative Encounter Resource之內容摘要以供人閱讀
... contained 0..* Resource Contained, inline Resources
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... medicalIdentity S 1..1 CodeableConcept 就醫身份
URL: https://fhir.cohesiondata.com/clinemr/StructureDefinition/cohesion-medicalidentity
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier 此就醫事件的識別碼
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (如果知道)
Binding: IdentifierUse (required): 如果知道,請說明此識別碼的用途;應填入所綁定值集中的其中一個代碼。

.... type S 1..1 CodeableConceptTW 識別碼(identifier)的型別說明
Binding: Identifier Type Codes (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。


Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: SNO
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
.... system SΣ 1..1 uri 識別碼(identifier)的命名空間(namespace)
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string 唯一值。[應填入門診病摘之掛號序號Visit Seq]
Example General: 123456
.... period Σ 0..1 Period 此就醫事件識別碼(identifier)的使用效期
.... assigner Σ 0..1 Reference(TW Core Organization) 簽發identifier的機構(可以只是文字表述)
... status ?!SΣ 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): 就醫現況的代碼;應填入所綁定值集中的其中一個代碼


Required Pattern: finished
... statusHistory 0..* BackboneElement 過去的就醫狀態清單
.... 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
.... status 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): 就醫現狀的代碼;應填入所綁定值集中的其中一個代碼

.... period 1..1 Period 該事件處於特定狀態的時間
... class S 1..1 CodingTW 病人就醫的分類
Binding: ActEncounterCode (extensible): 就醫的分類;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。


Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
.... version 0..1 string Version of the system - if relevant
.... code 1..1 code Symbol in syntax defined by the system
Fixed Value: AMB
.... display 0..1 string Representation defined by the system
.... userSelected 0..1 boolean If this coding was chosen directly by the user
... classHistory 0..* BackboneElement 過去就醫類別的列表
.... 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
.... class 1..1 Coding inpatient | outpatient | ambulatory | emergency +
Binding: ActEncounterCode (extensible): 就醫類別;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。

.... period 1..1 Period 此就醫事件處於特定類別的時間
... type 0..* CodeableConceptTW 就醫的特定型別
Binding: EncounterType (example): 就醫的型別;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。


... serviceType S 1..1 CodeableConceptTW 服務的特定型別。[應填入門診病摘之看診科別Dpartment]
Binding: ServiceType (example): 對提供的服務進行廣泛分類;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。

.... 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
Slice: Unordered, Open by pattern:system
..... coding:TWMedicalDepartmentSCT S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 對應至 SNOMED CT之就醫科別 + 診療科別值集 (required)
...... 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
...... system SΣ 1..1 uri 專門術語系統(terminology system)的識別
Required Pattern: http://snomed.info/sct
...... version Σ 0..1 string 系統的版本—如果相關的話
...... code SΣ 0..1 code 系統定義的語法之符號
...... display SΣ 0..1 string 由系統定義的表示法
...... userSelected Σ 0..1 boolean 此編碼是否由使用者直接選擇?
..... coding:TWMedicalConsultationDepartment S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 無法對應至SNOMED CT之臺灣健保署就醫科別值集 (required)
...... 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
...... system SΣ 1..1 uri 專門術語系統(terminology system)的識別
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-consultation-department-nhi-tw
...... version Σ 0..1 string 系統的版本—如果相關的話
...... code SΣ 0..1 code 系統定義的語法之符號
...... display SΣ 0..1 string 由系統定義的表示法
...... userSelected Σ 0..1 boolean 此編碼是否由使用者直接選擇?
..... coding:TWMedicalTreatmentDepartment S 0..1 CodingTW 由專門術語系統(terminology system)定義的代碼
Binding: 無法對應至SNOMED CT之臺灣健保署診療科別值集 (required)
...... 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
...... system SΣ 1..1 uri 專門術語系統(terminology system)的識別
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-treatment-department-nhi-tw
...... version Σ 0..1 string 系統的版本—如果相關的話
...... code SΣ 0..1 code 系統定義的語法之符號
...... display SΣ 0..1 string 由系統定義的表示法
...... userSelected Σ 0..1 boolean 此編碼是否由使用者直接選擇?
.... text SΣ 0..1 string 概念的文字表示法
... priority 0..1 CodeableConceptTW 表明就醫的急迫性
Binding: ActPriority (example): 表明就醫的迫切性;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。

... subject SΣ 0..1 Reference(病人資料(Patient ClinEMR)) 在場就醫的病人或實體集合(Group)
... episodeOfCare Σ 0..* Reference(EpisodeOfCare) 此次就醫應記錄的照護事件
... basedOn 0..* Reference(服務請求(ServiceRequest ClinEMR)) 開始此次就醫的服務請求(ServiceRequest)
... participant SΣ 0..* BackboneElement 參與就醫的健康照護服務提供者之名單
.... 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
.... type S 0..* CodeableConceptTW 參與者在病人就醫事件中的角色
Binding: ParticipantType (extensible): 參與者在病人就醫事件中的角色;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。


.... period S 0..1 Period 參與者在病人就醫期間參與的時段
.... individual SΣ 0..1 Reference(健康照護服務提供人員資料(Practitioner ClinEMR) | TW Core PractitionerRole | TW Core RelatedPerson) 除病人外,參與病人就醫事件的人。
... appointment Σ 0..* Reference(Appointment) 這次就醫的預約紀錄
... period S 1..1 Period 就醫的開始和結束時間
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... start SΣC 1..1 dateTime 就醫的開始時間。[應填入門診病摘之掛號(報到)日期時間Visit Date]
.... end ΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... length 0..1 Duration 就醫持續的時間(扣除缺席時間)
... reasonCode S 0..* CodeableConceptTW 就醫發生的編碼原因
Binding: EncounterReasonCodes (preferred): 發生此就醫事件的原因;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。


... reasonReference Σ 0..* Reference(病情、問題或診斷(ConditionDiagnosis ClinEMR) | 西醫-處置或手術(Procedure MCR) | 檢驗檢查(Observation ClinEMR) | ImmunizationRecommendation) 就醫發生的原因(參照)
... diagnosis Σ 0..* BackboneElement 與此就醫相關的診斷清單
.... 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
.... condition Σ 1..1 Reference(病情、問題或診斷(ConditionDiagnosis ClinEMR)) 與就醫事件相關的診斷或處置
.... use 0..1 CodeableConceptTW 此診斷在病人就醫事件中的作用(例如:住院、收費、出院...)。
Binding: DiagnosisRole (preferred): 此情況所代表的診斷型別;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。

.... rank 0..1 positiveInt 診斷的排序(針對每個角色型別)
... account 0..* Reference(Account) 可用於為此病人就醫事件計費的一組帳戶
... hospitalization S 0..1 BackboneElement 關於入院接受健康照護服務的細節
.... 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
.... preAdmissionIdentifier 0..1 Identifier 住院前識別碼
.... origin 0..1 Reference(醫事機構(Organization ClinEMR) | TW Core Location) 病人住院前來自的地點/機構
.... admitSource 0..1 CodeableConceptTW 病人從哪裡住院(醫生轉介、轉院)?
Binding: AdmitSource (preferred): 病人從哪裡住院;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。

.... reAdmission 0..1 CodeableConceptTW 已發生的醫院再入院型別(如果有的話)。如果該值不存在,則不被認定為再入院。
Binding: hl7VS-re-admissionIndicator (example): 這次住院就醫的再入院原因;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。

.... dietPreference 0..* CodeableConceptTW 病人報告的飲食偏好
Binding: Diet (example): 醫療、文化或道德方面的食物偏好,以幫助滿足飲食要求;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。


.... specialCourtesy 0..* CodeableConceptTW 特別禮遇(貴賓、董事會成員)
Binding: SpecialCourtesy (preferred): 特別禮遇;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。


.... specialArrangement 0..* CodeableConceptTW 輪椅、翻譯人員、擔架等。
Binding: SpecialArrangements (preferred): 特殊安排;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。


.... destination 0..1 Reference(TW Core Location | 醫事機構(Organization ClinEMR)) 病人出院地點/機構
.... dischargeDisposition S 0..1 CodeableConceptTW 出院後的地點類別或種類
Binding: DischargeDisposition (example): 出院處置;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。

... location S 0..* BackboneElement 病人曾去過的一個或多個地點
.... 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
.... location S 1..1 Reference(TW Core Location) 就醫發生的地點
.... status 0..1 code planned | active | reserved | completed
Binding: EncounterLocationStatus (required): 就醫地點的狀態;應填入所綁定值集中的其中一個代碼。

.... physicalType 0..1 CodeableConceptTW 地點的實體型別(通常是地點的層級—床位、房間、病房等)。
Binding: LocationType (example): 地點的實體型別;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 0..1 Period 病人出現在此地點的時段
... serviceProvider S 0..1 Reference(醫事機構(Organization ClinEMR)) 負責這次就醫的機構
... partOf 0..1 Reference(就醫事件(Encounter ClinEMR)) 此就醫是哪次就醫的一部份?

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Encounter.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Encounter.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Encounter.identifier.typeextensiblePattern: SNO
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Encounter.statusrequiredPattern: finished
http://hl7.org/fhir/ValueSet/encounter-status|4.0.1
from the FHIR Standard
Encounter.statusHistory.statusrequiredEncounterStatus
http://hl7.org/fhir/ValueSet/encounter-status|4.0.1
from the FHIR Standard
Encounter.classextensiblePattern: AMB
http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
Encounter.classHistory.classextensibleActEncounterCode
http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
Encounter.typeexampleEncounterType
http://hl7.org/fhir/ValueSet/encounter-type
from the FHIR Standard
Encounter.serviceTypeexampleServiceType
http://hl7.org/fhir/ValueSet/service-type
from the FHIR Standard
Encounter.serviceType.coding:TWMedicalDepartmentSCTrequiredTWMedicalDepartmentSCT
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/medical-department-sct-tw
Encounter.serviceType.coding:TWMedicalConsultationDepartmentrequiredTWMedicalConsultationDepartment
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/medical-consultation-department-tw
Encounter.serviceType.coding:TWMedicalTreatmentDepartmentrequiredTWMedicalTreatmentDepartment
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/medical-treatment-department-tw
Encounter.priorityexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Encounter.participant.typeextensibleParticipantType
http://hl7.org/fhir/ValueSet/encounter-participant-type
from the FHIR Standard
Encounter.reasonCodepreferredEncounterReasonCodes
http://hl7.org/fhir/ValueSet/encounter-reason
from the FHIR Standard
Encounter.diagnosis.usepreferredDiagnosisRole
http://hl7.org/fhir/ValueSet/diagnosis-role
from the FHIR Standard
Encounter.hospitalization.admitSourcepreferredAdmitSource
http://hl7.org/fhir/ValueSet/encounter-admit-source
from the FHIR Standard
Encounter.hospitalization.reAdmissionexampleHl7VSReAdmissionIndicator
http://terminology.hl7.org/ValueSet/v2-0092
Encounter.hospitalization.dietPreferenceexampleDiet
http://hl7.org/fhir/ValueSet/encounter-diet
from the FHIR Standard
Encounter.hospitalization.specialCourtesypreferredSpecialCourtesy
http://hl7.org/fhir/ValueSet/encounter-special-courtesy
from the FHIR Standard
Encounter.hospitalization.specialArrangementpreferredSpecialArrangements
http://hl7.org/fhir/ValueSet/encounter-special-arrangements
from the FHIR Standard
Encounter.hospitalization.dischargeDispositionexampleDischargeDisposition
http://hl7.org/fhir/ValueSet/encounter-discharge-disposition
from the FHIR Standard
Encounter.location.statusrequiredEncounterLocationStatus
http://hl7.org/fhir/ValueSet/encounter-location-status|4.0.1
from the FHIR Standard
Encounter.location.physicalTypeexampleLocationType
http://hl7.org/fhir/ValueSet/location-physical-type
from the FHIR Standard

This structure is derived from TWCoreEncounter

Summary

Mandatory: 7 elements
Must-Support: 3 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

 

Other representations of profile: CSV, Excel, Schematron