description: 此Profile用於描述門診病歷的報告文件 package_name: tw.gov.mohw.emr derivation: constraint name: PMRComposition type: Composition elements: status: pattern: {type: Code, value: final} index: 0 type: elements: text: short: 類型說明描述 pattern: {type: String, value: 門診病歷} index: 1 required: [text] subject: type: Reference short: 報告文件有關的對象及（或）事物。 refers: ['https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRPatient'] index: 2 elements: reference: {short: 關聯至門診病歷中的病人基本資料, mustSupport: true, index: 3} required: [reference] encounter: type: Reference short: 報告文件來自於哪次住院基本資料。 mustSupport: true refers: ['https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMREncounter'] index: 4 elements: reference: {short: 關聯至門診病歷中的門診日期、科別, mustSupport: true, index: 5} required: [reference] date: {short: 報告產生日期, index: 6} author: type: Reference short: 報告文件有關的創作部分。關聯至門診病歷中的醫事機構或醫師姓名 refers: ['https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMROrganization', 'https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRPractitioner'] index: 7 title: short: 報告文件的名字或標題 pattern: {type: String, value: 門診病歷} index: 8 section: short: 報告文件與哪些資料有關 array: true min: 8 index: 9 slicing: rules: open discriminator: - {path: code.coding.code, type: value} min: 8 slices: MedicationPrescribed: match: code: coding: {code: 29551-9} schema: short: 門診病歷中的處方內容(MedicationRequest) _required: true index: 96 elements: title: {short: '此筆關聯的資料標題為何?', index: 97} code: index: 98 elements: coding: index: 99 elements: system: pattern: {type: Uri, value: 'http://loinc.org'} index: 100 code: pattern: {type: Code, value: 29551-9} index: 101 display: pattern: {type: String, value: Medication prescribed Narrative} index: 102 required: [system, code] required: [coding] entry: short: 此筆關聯的資料 array: true min: 2 index: 103 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: 2 slices: MedicationRequest: match: {} schema: type: Reference refers: ['https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRMedicationRequest'] _required: true index: 104 elements: reference: {short: 關聯至門診病歷中的處方內容(MedicationRequest), index: 105} required: [reference] Medication: match: {} schema: type: Reference refers: ['https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRMedication'] _required: true index: 106 elements: reference: {short: 門診病歷中的處方內容(Medication), index: 107} required: [reference] required: [code] ObservationProfession: match: code: coding: {code: 21847-9} schema: short: 門診病歷中的病人基本資料_職業 index: 37 elements: title: {short: '此筆關聯的資料標題為何?', index: 38} code: index: 39 elements: coding: index: 40 elements: system: pattern: {type: Uri, value: 'http://loinc.org'} index: 41 code: pattern: {type: Code, value: 21847-9} index: 42 display: pattern: {type: String, value: Usual occupation Narrative} index: 43 required: [system, code] required: [coding] entry: type: Reference short: 此筆關聯的資料 refers: ['https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRProfessionObservation'] index: 44 elements: reference: {short: 關聯至門診病歷中的病人基本資料_職業, index: 45} required: [reference] required: [entry, code] ObservationLabResults: match: code: coding: {code: 19146-0} schema: short: 門診病歷中的病人基本資料_實驗室檢查紀錄 _required: true index: 10 elements: title: {short: '此筆關聯的資料標題為何?', index: 11} code: index: 12 elements: coding: index: 13 elements: system: pattern: {type: Uri, value: 'http://loinc.org'} index: 14 code: pattern: {type: Code, value: 19146-0} index: 15 display: pattern: {type: String, value: Referral lab test results} index: 16 required: [system, code] required: [coding] entry: type: Reference short: 此筆關聯的資料 refers: ['https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRObservationLabResults'] index: 17 elements: reference: {short: 關聯至門診病歷中的病人基本資料_實驗室檢查紀錄, index: 18} required: [reference] required: [entry, code] ClinicalImpression: match: code: coding: {code: 19824-2} schema: short: 門診病歷中的診斷病情摘要 _required: true index: 64 elements: title: {short: '此筆關聯的資料標題為何?', index: 65} code: index: 66 elements: coding: index: 67 elements: system: pattern: {type: Uri, value: 'http://loinc.org'} index: 68 code: pattern: {type: Code, value: 19824-2} index: 69 display: pattern: {type: String, value: Return visit conditions} index: 70 required: [system, code] required: [coding] entry: type: Reference short: 此筆關聯的資料 refers: ['https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRClinicalImpressionAssessment', 'https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRClinicalImpressionObjective', 'https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRClinicalImpressionSubjective'] array: true min: 3 index: 71 slicing: rules: open discriminator: - {path: identifier.value, type: value} min: 3 slices: ClinicalImpression_Subjective: match: identifier: {value: 61150-9} schema: type: Reference refers: ['https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRClinicalImpressionSubjective'] _required: true index: 72 elements: reference: {short: 關聯至門診病歷中的診斷病情摘要_Subjective, index: 73} identifier: index: 74 elements: system: pattern: {type: Uri, value: 'http://loinc.org'} index: 75 value: pattern: {type: String, value: 61150-9} index: 76 required: [value, system] required: [identifier, reference] ClinicalImpression_Objective: match: identifier: {value: 61149-1} schema: type: Reference refers: ['https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRClinicalImpressionObjective'] _required: true index: 77 elements: reference: {short: 關聯至門診病歷中的病人基本資料_Objective, index: 78} identifier: index: 79 elements: system: pattern: {type: Uri, value: 'http://loinc.org'} index: 80 value: pattern: {type: String, value: 61149-1} index: 81 required: [value, system] required: [identifier, reference] ClinicalImpression_Assessment: match: identifier: {value: 11494-2} schema: type: Reference refers: ['https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRClinicalImpressionAssessment'] _required: true index: 82 elements: reference: {short: 關聯至門診病歷中的病人基本資料_ Assessment, index: 83} identifier: index: 84 elements: system: pattern: {type: Uri, value: 'http://loinc.org'} index: 85 value: pattern: {type: String, value: 11494-2} index: 86 required: [value, system] required: [identifier, reference] required: [code] ConditionMajorIllness: match: code: coding: {code: 11338-1} schema: short: 門診病歷中的病人基本資料_重大傷病 _required: true index: 19 elements: title: {short: '此筆關聯的資料標題為何?', index: 20} code: index: 21 elements: coding: index: 22 elements: system: pattern: {type: Uri, value: 'http://loinc.org'} index: 23 code: pattern: {type: Code, value: 11338-1} index: 24 display: pattern: {type: String, value: History of Major illnesses and injuries Narrative} index: 25 required: [system, code] required: [coding] entry: type: Reference short: 此筆關聯的資料 refers: ['https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRConditionMajorIllness'] index: 26 elements: reference: {short: 關聯至門診病歷中的病人基本資料_重大傷病, index: 27} required: [reference] required: [entry, code] ConditionDiagnosis: match: code: coding: {code: 29548-5} schema: short: 門診病歷中的診斷 _required: true index: 55 elements: title: {short: '此筆關聯的資料標題為何?', index: 56} code: index: 57 elements: coding: index: 58 elements: system: pattern: {type: Uri, value: 'http://loinc.org'} index: 59 code: pattern: {type: Code, value: 29548-5} index: 60 display: pattern: {type: String, value: Diagnosis Narrative} index: 61 required: [system, code] required: [coding] entry: type: Reference short: 此筆關聯的資料 refers: ['https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRConditionDiagnosis'] index: 62 elements: reference: {short: 關聯至門診病歷中的診斷, index: 63} required: [reference] required: [entry, code] MediaOutpatientImage: match: code: coding: {code: 19005-8} schema: short: 門診病歷中的門診圖像 index: 117 elements: title: {short: '此筆關聯的資料標題為何?', index: 118} code: index: 119 elements: coding: index: 120 elements: system: pattern: {type: Uri, value: 'http://loinc.org'} index: 121 code: pattern: {type: Code, value: 19005-8} index: 122 display: pattern: {type: String, value: 'Radiology Imaging study [Impression] (narrative)'} index: 123 required: [system, code] required: [coding] entry: type: Reference short: 此筆關聯的資料 refers: ['https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMROutpatientImageMedia'] index: 124 elements: reference: {short: 關聯至門診病歷中的門診圖像, index: 125} required: [reference] required: [entry, code] MediaFamilyTree: match: code: coding: {code: 74027-4} schema: short: 門診病歷中的家族圖譜 index: 108 elements: title: {short: '此筆關聯的資料標題為何?', index: 109} code: index: 110 elements: coding: index: 111 elements: system: pattern: {type: Uri, value: 'http://loinc.org'} index: 112 code: pattern: {type: Code, value: 74027-4} index: 113 display: pattern: {type: String, value: Family pedigree identifier} index: 114 required: [system, code] required: [coding] entry: type: Reference short: 此筆關聯的資料 refers: ['https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRFamilyTreeMedia'] index: 115 elements: reference: {short: 關聯至門診病歷中的家族圖譜, index: 116} required: [reference] required: [entry, code] CoverageIdentifier: match: code: coding: {code: 63513-6} schema: short: 門診病歷中的病人基本資料_就醫身分別 _required: true index: 46 elements: title: {short: '此筆關聯的資料標題為何?', mustSupport: false, index: 47} code: index: 48 elements: coding: index: 49 elements: system: pattern: {type: Uri, value: 'http://loinc.org'} index: 50 code: pattern: {type: Code, value: 63513-6} index: 51 display: pattern: {type: String, value: 'Are you covered by health insurance or some other kind of health care plan [PhenX]'} index: 52 required: [system, code] required: [coding] entry: type: Reference short: 此筆關聯的資料 refers: ['https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/Coverage-EMR'] index: 53 elements: reference: {short: 關聯至門診病歷中的病人基本資料_就醫身分別, index: 54} required: [reference] required: [entry, code] Procedure: match: code: coding: {code: 29554-3} schema: short: 門診病歷中的處置項目 _required: true index: 87 elements: title: {short: '此筆關聯的資料標題為何?', index: 88} code: index: 89 elements: coding: index: 90 elements: system: pattern: {type: Uri, value: 'http://loinc.org'} index: 91 code: pattern: {type: Code, value: 29554-3} index: 92 display: pattern: {type: String, value: Procedure Narrative} index: 93 required: [system, code] required: [coding] entry: type: Reference short: 此筆關聯的資料 refers: ['https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRProcedure'] index: 94 elements: reference: {short: 關聯至門診病歷中的處置項目, index: 95} required: [reference] required: [entry, code] AllergyIntolerance: match: code: coding: {code: 10155-0} schema: short: 門診病歷中的病人基本資料_過敏史 _required: true index: 28 elements: title: {short: '此筆關聯的資料標題為何?', index: 29} code: index: 30 elements: coding: index: 31 elements: system: pattern: {type: Uri, value: 'http://loinc.org'} index: 32 code: pattern: {type: Code, value: 10155-0} index: 33 display: pattern: {type: String, value: 'History of allergies, reported'} index: 34 required: [system, code] required: [coding] entry: type: Reference short: 此筆關聯的資料 refers: ['https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRAllergyIntolerance'] index: 35 elements: reference: {short: 關聯至門診病歷中的病人基本資料_過敏史, index: 36} required: [reference] required: [entry, code] package_version: 0.2.0 class: profile kind: resource url: https://twcore.mohw.gov.tw/ig/emr/StructureDefinition/PMRComposition base: https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Composition-twcore version: 0.2.0 required: [encounter]