description: 此Profile用於描述牙醫診所門診病摘的報告文件 package_name: tw.cohesion.fhir.clinemr derivation: constraint name: CompositionDCR type: Composition elements: date: {short: '[應填入文件產生時間Create Time]', index: 12} meta: short: 應填入於牙醫診所門診病摘之病歷表單版本號Sheet Version mustSupport: true index: 0 elements: versionId: {mustSupport: true, index: 1} required: [versionId] encounter: type: Reference mustSupport: true refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/encounter-clinemr'] index: 10 elements: reference: {mustSupport: true, index: 11} required: [reference] section: array: true min: 4 index: 23 elements: author: type: Reference refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/organization-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/patient-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/practitioner-clinemr', 'https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/PractitionerRole-twcore'] index: 24 slicing: rules: open discriminator: - {path: code, type: value} min: 4 slices: DocumentReference: match: code: coding: - {code: 75310-3, system: 'http://loinc.org', display: Health concerns Document} schema: mustSupport: true index: 132 elements: title: {index: 133} code: pattern: type: CodeableConcept value: coding: - {code: 75310-3, system: 'http://loinc.org', display: Health concerns Document} index: 134 author: type: Reference refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/organization-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/patient-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/practitioner-clinemr', 'https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/PractitionerRole-twcore'] index: 135 entry: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/documentreference-clinemr'] index: 136 elements: reference: {index: 137} required: [reference] required: [entry, title, code] ObservationLabResults: match: code: coding: - {code: 30954-2, system: 'http://loinc.org', display: Relevant diagnostic tests/laboratory data Narrative} schema: mustSupport: true index: 111 elements: title: {index: 112} code: pattern: type: CodeableConcept value: coding: - {code: 30954-2, system: 'http://loinc.org', display: Relevant diagnostic tests/laboratory data Narrative} index: 113 author: type: Reference refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/organization-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/patient-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/practitioner-clinemr', 'https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/PractitionerRole-twcore'] index: 114 section: array: true min: 3 index: 115 slicing: rules: closed discriminator: - {path: entry.resolve(), type: profile} min: 3 slices: observation: match: {} schema: type: BackboneElement array: true min: 1 _required: true index: 116 elements: code: pattern: type: CodeableConcept value: coding: - {code: 19146-0, system: 'http://loinc.org', display: Referral lab test results} index: 117 entry: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/observation-clinemr'] index: 118 elements: reference: {index: 119} required: [reference] servicerequest: match: {} schema: type: BackboneElement array: true min: 1 _required: true index: 120 elements: code: pattern: type: CodeableConcept value: coding: - {code: 77597-3, system: 'http://loinc.org', display: Orders placed Document} index: 121 entry: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/servicerequest-clinemr'] index: 122 elements: reference: {index: 123} required: [reference] diagnosticreport: match: {} schema: type: BackboneElement array: true index: 124 elements: code: pattern: type: CodeableConcept value: coding: - {code: 50398-7, system: 'http://loinc.org', display: 'Narrative diagnostic report [Interpretation]'} index: 125 entry: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/diagnosticreport-clinemr'] index: 126 elements: reference: {index: 127} required: [reference] organizationinspection: match: {} schema: type: BackboneElement array: true min: 1 _required: true index: 128 elements: code: pattern: type: CodeableConcept value: coding: - {code: 52482-7, system: 'http://loinc.org', display: Laboratory} index: 129 entry: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/organizationinspection-clinemr'] index: 130 elements: reference: {index: 131} required: [reference] required: [title, code] ConditionMajorIllness: match: code: coding: - {code: 11338-1, system: 'http://loinc.org', display: History of Major illnesses and injuries Narrative} schema: mustSupport: true _required: true index: 54 elements: title: {index: 55} code: pattern: type: CodeableConcept value: coding: - {code: 11338-1, system: 'http://loinc.org', display: History of Major illnesses and injuries Narrative} index: 56 author: type: Reference refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/organization-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/patient-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/practitioner-clinemr', 'https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/PractitionerRole-twcore'] index: 57 entry: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/observationmajorillness-clinemr'] index: 58 section: type: BackboneElement index: 59 elements: code: pattern: type: CodeableConcept value: coding: - {code: 11338-1, system: 'http://loinc.org', display: History of Major illnesses and injuries Narrative} index: 60 entry: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/conditionmajorillness-clinemr'] index: 61 elements: reference: {index: 62} required: [reference] required: [entry, title, code] PatientInformation: match: code: coding: - {code: 52460-3, system: 'http://loinc.org', display: Patient Information} schema: mustSupport: true index: 25 elements: title: {index: 26} code: pattern: type: CodeableConcept value: coding: - {code: 52460-3, system: 'http://loinc.org', display: Patient Information} index: 27 author: type: Reference refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/organization-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/patient-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/practitioner-clinemr', 'https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/PractitionerRole-twcore'] index: 28 section: array: true max: 3 index: 29 slicing: rules: open discriminator: - {path: entry.resolve(), type: profile} min: null max: 3 slices: educationlevel: match: {} schema: type: BackboneElement index: 30 elements: code: pattern: type: CodeableConcept value: coding: - {code: 80913-7, system: 'http://loinc.org', display: 'Highest level of education [US Standard Certificate of Death]'} index: 31 entry: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/observationeducationlevel-clinemr'] index: 32 elements: reference: {index: 33} required: [reference] occupation: match: {} schema: type: BackboneElement index: 34 elements: code: pattern: type: CodeableConcept value: coding: - {code: 85658-3, system: 'http://loinc.org', display: 'Occupation [Type]'} index: 35 entry: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/observationoccupation-clinemr'] index: 36 elements: reference: {index: 37} required: [reference] bloodtype: match: {} schema: type: BackboneElement index: 38 elements: code: pattern: type: CodeableConcept value: coding: - {code: 882-1, system: 'http://loinc.org', display: 'ABO and Rh group [Type] in Blood'} index: 39 entry: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/observationbloodtype-clinemr'] index: 40 elements: reference: {index: 41} required: [reference] required: [title, code] ObservationVitalSign: match: code: coding: - {code: 8716-3, system: 'http://loinc.org', display: Vital signs} schema: mustSupport: true _required: true index: 99 elements: title: {index: 100} code: pattern: type: CodeableConcept value: coding: - {code: 8716-3, system: 'http://loinc.org', display: Vital signs} index: 101 author: type: Reference refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/organization-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/patient-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/practitioner-clinemr', 'https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/PractitionerRole-twcore'] index: 102 entry: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/observationvitalsign-clinemr'] index: 103 elements: reference: {index: 104} required: [reference] required: [title, code] ConditionDiagnosis: match: code: coding: - {code: 11450-4, system: 'http://loinc.org', display: Problem list - Reported} schema: mustSupport: true _required: true index: 76 elements: title: {index: 77} code: pattern: type: CodeableConcept value: coding: - {code: 11450-4, system: 'http://loinc.org', display: Problem list - Reported} index: 78 author: type: Reference refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/organization-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/patient-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/practitioner-clinemr', 'https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/PractitionerRole-twcore'] index: 79 section: array: true min: 3 index: 80 slicing: rules: open discriminator: - {path: entry.resolve(), type: profile} min: 3 slices: conditiondiagnosis: match: {} schema: type: BackboneElement array: true min: 1 _required: true index: 81 elements: code: pattern: type: CodeableConcept value: coding: - {code: 29548-5, system: 'http://loinc.org', display: Diagnosis Narrative} index: 82 entry: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/conditiondiagnosis-clinemr'] index: 83 elements: reference: {index: 84} required: [reference] practitioner: match: {} schema: type: BackboneElement _required: true index: 85 elements: code: pattern: type: CodeableConcept value: coding: - {code: 18600-7, system: 'http://loinc.org', display: Primary practitioner identifier} index: 86 entry: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/practitioner-clinemr'] index: 87 elements: reference: {index: 88} required: [reference] careplan: match: {} schema: type: BackboneElement _required: true index: 89 elements: code: pattern: type: CodeableConcept value: coding: - {code: 101541-1, system: 'http://loinc.org', display: Multidisciplinary Comprehensive plan of care note} index: 90 entry: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/careplan-clinemr'] index: 91 elements: reference: {index: 92} required: [reference] required: [title, code] ConditionChiefComplaint: match: code: coding: - {code: 10154-3, system: 'http://loinc.org', display: Chief complaint Narrative - Reported} schema: mustSupport: true _required: true index: 93 elements: title: {index: 94} code: pattern: type: CodeableConcept value: coding: - {code: 10154-3, system: 'http://loinc.org', display: Chief complaint Narrative - Reported} index: 95 author: type: Reference refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/organization-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/patient-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/practitioner-clinemr', 'https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/PractitionerRole-twcore'] index: 96 entry: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/conditionchiefcomplaint-clinemr'] index: 97 elements: reference: {index: 98} required: [reference] required: [title, code] Medication: match: code: coding: - {code: 10160-0, system: 'http://loinc.org', display: History of Medication use Narrative} schema: mustSupport: true index: 63 elements: title: {index: 64} code: pattern: type: CodeableConcept value: coding: - {code: 10160-0, system: 'http://loinc.org', display: History of Medication use Narrative} index: 65 author: type: Reference refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/organization-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/patient-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/practitioner-clinemr', 'https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/PractitionerRole-twcore'] index: 66 section: array: true min: 2 index: 67 slicing: rules: closed discriminator: - {path: entry.resolve(), type: profile} min: 2 slices: medication: match: {} schema: type: BackboneElement array: true min: 1 _required: true index: 68 elements: code: pattern: type: CodeableConcept value: coding: - {code: 87232-5, system: 'http://loinc.org', display: Medication administration.brief} index: 69 entry: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/medication-clinemr'] index: 70 elements: reference: {index: 71} required: [reference] medicationrequest: match: {} schema: type: BackboneElement array: true min: 1 _required: true index: 72 elements: code: pattern: type: CodeableConcept value: coding: - {code: 57833-6, system: 'http://loinc.org', display: Prescription for medication} index: 73 entry: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/medicationrequest-clinemr'] index: 74 elements: reference: {index: 75} required: [reference] required: [title, code] Procedure: match: code: coding: - {code: 29554-3, system: 'http://loinc.org', display: Procedure Narrative} schema: mustSupport: true index: 105 elements: title: {index: 106} code: pattern: type: CodeableConcept value: coding: - {code: 29554-3, system: 'http://loinc.org', display: Procedure Narrative} index: 107 author: type: Reference refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/organization-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/patient-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/practitioner-clinemr', 'https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/PractitionerRole-twcore'] index: 108 entry: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/procedure-dcr'] index: 109 elements: reference: {index: 110} required: [reference] required: [entry, title, code] AllergyIntolerance: match: code: coding: - {code: 48765-2, system: 'http://loinc.org', display: Allergies and adverse reactions Document} schema: mustSupport: true index: 42 elements: title: {index: 43} code: pattern: type: CodeableConcept value: coding: - {code: 48765-2, system: 'http://loinc.org', display: Allergies and adverse reactions Document} index: 44 author: type: Reference refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/organization-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/patient-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/practitioner-clinemr', 'https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/PractitionerRole-twcore'] index: 45 entry: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/allergyintolerance-clinemr'] index: 46 elements: reference: {index: 47} required: [reference] required: [title, code] ConditionPastMedicalHistory: match: code: coding: - {code: 11348-0, system: 'http://loinc.org', display: History of Past illness Narrative} schema: mustSupport: true index: 48 elements: title: {index: 49} code: pattern: type: CodeableConcept value: coding: - {code: 11348-0, system: 'http://loinc.org', display: History of Past illness Narrative} index: 50 author: type: Reference refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/organization-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/patient-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/practitioner-clinemr', 'https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/PractitionerRole-twcore'] index: 51 entry: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/conditionpastmedicalhistory-clinemr'] index: 52 elements: reference: {index: 53} required: [reference] required: [title, code] attester: elements: party: type: Reference refers: ['http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/organization-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/patient-clinemr', 'https://fhir.cohesiondata.com/clinemr/StructureDefinition/practitioner-clinemr', 'https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/PractitionerRole-twcore'] index: 17 type: pattern: type: CodeableConcept value: coding: - {code: 34108-1, system: 'http://loinc.org', display: Outpatient Note} index: 7 title: short: 固定值。[應填入病歷表單名稱Sheet Name] pattern: {type: String, value: 牙醫門診單} index: 15 author: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/organization-clinemr'] index: 13 elements: reference: {mustSupport: true, index: 14} required: [reference] custodian: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/organization-clinemr'] index: 18 status: pattern: {type: Code, value: final} index: 6 identifier: short: 不分版本的臨床文件架構(Composition)識別碼。[應填入於牙醫診所門診病摘之病歷表單編號] index: 2 elements: type: pattern: type: CodeableConcept value: coding: - {code: SNO, system: 'http://terminology.hl7.org/CodeSystem/v2-0203'} index: 3 value: {index: 4} assigner: type: Reference refers: ['https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Organization-twcore'] index: 5 required: [value, type] relatesTo: elements: target: choices: [targetIdentifier, targetReference] index: 20 targetIdentifier: {type: Identifier, choiceOf: target, index: 21} targetReference: type: Reference choiceOf: target refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/composition-dcr'] index: 22 subject: type: Reference refers: ['https://fhir.cohesiondata.com/clinemr/StructureDefinition/patient-clinemr'] index: 8 elements: reference: {mustSupport: true, index: 9} required: [reference] confidentiality: {short: '[應填入文件敏感性Doc Confidentiality Code]', mustSupport: true, index: 16} package_version: 1.0.0 class: profile kind: resource url: https://fhir.cohesiondata.com/clinemr/StructureDefinition/composition-dcr base: https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Composition-twcore version: 1.0.0 required: [confidentiality, identifier, meta]