{
"description": "手術紀錄(OperationNote)之資料模型",
"_filename": "StructureDefinition-OperationNoteModel.json",
"package_name": "tw.cathay.fhir.imri",
"date": "2024-11-26T22:24:42+08:00",
"derivation": "specialization",
"publisher": "國泰金控",
"fhirVersion": "4.0.1",
"name": "OperationNoteModel",
"mapping": [ {
"uri": "https://imri.cgh.org.tw/imri/",
"name": "IMRI",
"identity": "OperationNote"
} ],
"abstract": false,
"type": "https://imri.cgh.org.tw/imri/StructureDefinition/OperationNoteModel",
"experimental": null,
"resourceType": "StructureDefinition",
"title": "手術紀錄(OperationNote)之資料模型",
"package_version": "1.0.0",
"snapshot": {
"element": [ {
"path": "OperationNoteModel",
"min": 0,
"definition": "手術紀錄(OperationNote)之資料模型",
"isModifier": false,
"short": "手術紀錄(OperationNote)之資料模型",
"mapping": [ {
"map": "BundleOperationNoteIMRI",
"identity": "OperationNote"
} ],
"max": "*",
"id": "OperationNoteModel",
"base": {
"max": "*",
"min": 0,
"path": "Base"
}
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "OperationNoteModel.organization",
"min": 1,
"definition": "醫事機構",
"short": "醫事機構",
"type": [ {
"code": "BackboneElement"
} ],
"max": "1",
"id": "OperationNoteModel.organization",
"base": {
"max": "1",
"min": 1,
"path": "OperationNoteModel.organization"
}
}, {
"path": "OperationNoteModel.organization.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "OperationNoteModel.organization.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "OperationNoteModel.organization.extension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"slicing": {
"rules": "open",
"description": "Extensions are always sliced by (at least) url",
"discriminator": [ {
"path": "url",
"type": "value"
} ]
},
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "OperationNoteModel.organization.extension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "OperationNoteModel.organization.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "OperationNoteModel.organization.modifierExtension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"path": "OperationNoteModel.organization.identifier",
"min": 1,
"definition": "醫事機構代碼",
"short": "醫事機構代碼",
"mapping": [ {
"map": "entry:OrganizationHospIMRI.identifier",
"identity": "OperationNote"
} ],
"type": [ {
"code": "Identifier"
} ],
"max": "1",
"id": "OperationNoteModel.organization.identifier",
"base": {
"max": "1",
"min": 1,
"path": "OperationNoteModel.organization.identifier"
}
}, {
"path": "OperationNoteModel.organization.name",
"min": 1,
"definition": "醫事機構名稱",
"short": "醫事機構名稱",
"mapping": [ {
"map": "entry:OrganizationHospIMRI.name",
"identity": "OperationNote"
} ],
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "OperationNoteModel.organization.name",
"base": {
"max": "1",
"min": 1,
"path": "OperationNoteModel.organization.name"
}
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "OperationNoteModel.patient",
"min": 1,
"definition": "病人的基本資料",
"short": "病人的基本資料",
"type": [ {
"code": "BackboneElement"
} ],
"max": "1",
"id": "OperationNoteModel.patient",
"base": {
"max": "1",
"min": 1,
"path": "OperationNoteModel.patient"
}
}, {
"path": "OperationNoteModel.patient.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "OperationNoteModel.patient.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "OperationNoteModel.patient.extension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"slicing": {
"rules": "open",
"description": "Extensions are always sliced by (at least) url",
"discriminator": [ {
"path": "url",
"type": "value"
} ]
},
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "OperationNoteModel.patient.extension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "OperationNoteModel.patient.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "OperationNoteModel.patient.modifierExtension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"path": "OperationNoteModel.patient.identifier",
"min": 1,
"definition": "身分證字號",
"short": "身分證字號",
"mapping": [ {
"map": "entry:PatientIMRI.identifier:idCardNumber",
"identity": "OperationNote"
} ],
"type": [ {
"code": "Identifier"
} ],
"max": "1",
"id": "OperationNoteModel.patient.identifier",
"base": {
"max": "1",
"min": 1,
"path": "OperationNoteModel.patient.identifier"
}
}, {
"path": "OperationNoteModel.patient.patientNo",
"min": 1,
"definition": "病歷號碼",
"short": "病歷號碼",
"mapping": [ {
"map": "entry:PatientIMRI.identifier:medicalRecord",
"identity": "OperationNote"
} ],
"type": [ {
"code": "Identifier"
} ],
"max": "1",
"id": "OperationNoteModel.patient.patientNo",
"base": {
"max": "1",
"min": 1,
"path": "OperationNoteModel.patient.patientNo"
}
}, {
"path": "OperationNoteModel.patient.name",
"min": 1,
"definition": "病人之合法姓名。",
"short": "姓名",
"mapping": [ {
"map": "entry:PatientIMRI.name",
"identity": "OperationNote"
} ],
"type": [ {
"code": "HumanName"
} ],
"max": "*",
"id": "OperationNoteModel.patient.name",
"base": {
"max": "*",
"min": 1,
"path": "OperationNoteModel.patient.name"
}
}, {
"path": "OperationNoteModel.patient.gender",
"min": 1,
"definition": "性別",
"short": "性別",
"mapping": [ {
"map": "entry:PatientIMRI.gender",
"identity": "OperationNote"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"max": "1",
"id": "OperationNoteModel.patient.gender",
"base": {
"max": "1",
"min": 1,
"path": "OperationNoteModel.patient.gender"
}
}, {
"path": "OperationNoteModel.patient.birthDate",
"min": 1,
"definition": "病人的生日，如果有完整或部分的生日日期則必須提供，若無完整或部分的生日日期則以空字串''表示之。",
"short": "出生日期",
"mapping": [ {
"map": "entry:PatientIMRI.birthDate",
"identity": "OperationNote"
} ],
"type": [ {
"code": "dateTime"
} ],
"max": "1",
"id": "OperationNoteModel.patient.birthDate",
"base": {
"max": "1",
"min": 1,
"path": "OperationNoteModel.patient.birthDate"
}
}, {
"path": "OperationNoteModel.patient.bloodtype",
"min": 0,
"definition": "血型",
"short": "血型",
"mapping": [ {
"map": "entry:ObservationBloodTypeIMRI.valueCodeableConcept",
"identity": "OperationNote"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"max": "1",
"id": "OperationNoteModel.patient.bloodtype",
"base": {
"max": "1",
"min": 0,
"path": "OperationNoteModel.patient.bloodtype"
}
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "OperationNoteModel.operation",
"min": 1,
"definition": "手術資料",
"short": "手術資料",
"type": [ {
"code": "BackboneElement"
} ],
"max": "1",
"id": "OperationNoteModel.operation",
"base": {
"max": "1",
"min": 1,
"path": "OperationNoteModel.operation"
}
}, {
"path": "OperationNoteModel.operation.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "OperationNoteModel.operation.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "OperationNoteModel.operation.extension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"slicing": {
"rules": "open",
"description": "Extensions are always sliced by (at least) url",
"discriminator": [ {
"path": "url",
"type": "value"
} ]
},
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "OperationNoteModel.operation.extension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "OperationNoteModel.operation.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "OperationNoteModel.operation.modifierExtension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"path": "OperationNoteModel.operation.operationDateTime",
"min": 1,
"definition": "手術日期時間",
"short": "手術日期時間",
"mapping": [ {
"map": "entry:ProcedureOperationIMRI.performedDateTime",
"identity": "OperationNote"
} ],
"type": [ {
"code": "dateTime"
} ],
"max": "1",
"id": "OperationNoteModel.operation.operationDateTime",
"base": {
"max": "1",
"min": 1,
"path": "OperationNoteModel.operation.operationDateTime"
}
}, {
"path": "OperationNoteModel.operation.preoperativeDiagnosis",
"min": 1,
"definition": "手術前診斷",
"short": "手術前診斷",
"mapping": [ {
"map": "entry:ProcedureOperationIMRI.reasonReference.Reference(TWCoreCondition).code.coding.code",
"identity": "OperationNote"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"max": "*",
"id": "OperationNoteModel.operation.preoperativeDiagnosis",
"base": {
"max": "*",
"min": 1,
"path": "OperationNoteModel.operation.preoperativeDiagnosis"
}
}, {
"path": "OperationNoteModel.operation.postoperativeDiagnosis[x]",
"min": 0,
"definition": "手術後診斷",
"short": "手術後診斷",
"mapping": [ {
"map": "entry:CompositionOperationNoteIMRI.section:OperationNote.section:postoperativeDiagnosis.text 或 entry:TWCoreCondition.code.coding.code",
"identity": "OperationNote"
} ],
"type": [ {
"code": "Narrative"
}, {
"code": "CodeableConcept"
} ],
"max": "*",
"id": "OperationNoteModel.operation.postoperativeDiagnosis[x]",
"base": {
"max": "*",
"min": 0,
"path": "OperationNoteModel.operation.postoperativeDiagnosis[x]"
}
}, {
"path": "OperationNoteModel.operation.operationCode",
"min": 1,
"definition": "手術代碼",
"short": "手術代碼",
"mapping": [ {
"map": "entry:ProcedureOperationIMRI.code.coding.code",
"identity": "OperationNote"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"max": "1",
"id": "OperationNoteModel.operation.operationCode",
"base": {
"max": "1",
"min": 1,
"path": "OperationNoteModel.operation.operationCode"
}
}, {
"path": "OperationNoteModel.operation.bodyPart",
"min": 0,
"definition": "手術部位",
"short": "手術部位",
"mapping": [ {
"map": "entry:ProcedureOperationIMRI.bodySite",
"identity": "OperationNote"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"max": "*",
"id": "OperationNoteModel.operation.bodyPart",
"base": {
"max": "*",
"min": 0,
"path": "OperationNoteModel.operation.bodyPart"
}
}, {
"path": "OperationNoteModel.operation.indication",
"min": 1,
"definition": "手術目的",
"short": "手術目的",
"mapping": [ {
"map": "entry:ProcedureOperationIMRI.code.coding.display",
"identity": "OperationNote"
} ],
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "OperationNoteModel.operation.indication",
"base": {
"max": "1",
"min": 1,
"path": "OperationNoteModel.operation.indication"
}
}, {
"path": "OperationNoteModel.operation.bloodLoss[x]",
"min": 0,
"definition": "失血量",
"short": "失血量",
"mapping": [ {
"map": "entry:CompositionOperationNoteIMRI.section:OperationNote.section:bloodLoss.text 或 entry:ObservationBloodLossIMRI.valueQuantity.value",
"identity": "OperationNote"
} ],
"type": [ {
"code": "Narrative"
}, {
"code": "decimal"
} ],
"max": "1",
"id": "OperationNoteModel.operation.bloodLoss[x]",
"base": {
"max": "1",
"min": 0,
"path": "OperationNoteModel.operation.bloodLoss[x]"
}
}, {
"path": "OperationNoteModel.operation.anesthesiaMode[x]",
"min": 0,
"definition": "麻醉模式",
"short": "麻醉模式",
"mapping": [ {
"map": "entry:CompositionOperationNoteIMRI.section:OperationNote.section:anesthesiaMode.text 或 entry:ProcedureAnesthesiaModeIMRI.code",
"identity": "OperationNote"
} ],
"type": [ {
"code": "Narrative"
}, {
"code": "CodeableConcept"
} ],
"max": "1",
"id": "OperationNoteModel.operation.anesthesiaMode[x]",
"base": {
"max": "1",
"min": 0,
"path": "OperationNoteModel.operation.anesthesiaMode[x]"
}
}, {
"path": "OperationNoteModel.operation.anesthesiologist",
"min": 0,
"definition": "麻醉醫師",
"short": "麻醉醫師",
"mapping": [ {
"map": "entry:ProcedureAnesthesiaModeIMRI.performer.actor.Reference(PractitionerRoleIMRI).where(code = '88189002').practitioner.Reference(PractitionerIMRI).name",
"identity": "OperationNote"
} ],
"type": [ {
"code": "HumanName"
} ],
"max": "*",
"id": "OperationNoteModel.operation.anesthesiologist",
"base": {
"max": "*",
"min": 0,
"path": "OperationNoteModel.operation.anesthesiologist"
}
}, {
"path": "OperationNoteModel.operation.operativeFinding",
"min": 1,
"definition": "手術發現",
"short": "手術發現",
"mapping": [ {
"map": "entry:ProcedureOperationIMRI.note[0].text",
"identity": "OperationNote"
} ],
"type": [ {
"code": "markdown"
} ],
"max": "*",
"id": "OperationNoteModel.operation.operativeFinding",
"base": {
"max": "*",
"min": 1,
"path": "OperationNoteModel.operation.operativeFinding"
}
}, {
"path": "OperationNoteModel.operation.operationProcedure",
"min": 1,
"definition": "手術過程紀錄",
"short": "手術過程紀錄",
"mapping": [ {
"map": "entry:ProcedureOperationIMRI.note[1].text",
"identity": "OperationNote"
} ],
"type": [ {
"code": "markdown"
} ],
"max": "*",
"id": "OperationNoteModel.operation.operationProcedure",
"base": {
"max": "*",
"min": 1,
"path": "OperationNoteModel.operation.operationProcedure"
}
}, {
"path": "OperationNoteModel.operation.device",
"min": 0,
"definition": "手術特材",
"short": "手術特材",
"mapping": [ {
"map": "entry:ProcedureOperationIMRI.usedCode",
"identity": "OperationNote"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"max": "*",
"id": "OperationNoteModel.operation.device",
"base": {
"max": "*",
"min": 0,
"path": "OperationNoteModel.operation.device"
}
}, {
"path": "OperationNoteModel.operation.surgeon",
"min": 0,
"definition": "手術醫師",
"short": "手術醫師",
"mapping": [ {
"map": "entry:ProcedureOperationIMRI.performer.actor.Reference(PractitionerRoleIMRI).where(code = '304292004').practitioner.Reference(PractitionerIMRI).name",
"identity": "OperationNote"
} ],
"type": [ {
"code": "HumanName"
} ],
"max": "*",
"id": "OperationNoteModel.operation.surgeon",
"base": {
"max": "*",
"min": 0,
"path": "OperationNoteModel.operation.surgeon"
}
}, {
"path": "OperationNoteModel.operation.surgicalImage",
"min": 0,
"definition": "手術圖像",
"short": "手術圖像",
"mapping": [ {
"map": "entry:ProcedureOperationIMRI.report.Reference(TWCoreDocumentReference).content.attachment.url",
"identity": "OperationNote"
} ],
"type": [ {
"code": "url"
} ],
"max": "*",
"id": "OperationNoteModel.operation.surgicalImage",
"base": {
"max": "*",
"min": 0,
"path": "OperationNoteModel.operation.surgicalImage"
}
} ]
},
"status": "active",
"id": "a006ff81-c8bf-45cb-8d3f-69ce6ed59fb4",
"kind": "logical",
"url": "https://imri.cgh.org.tw/imri/StructureDefinition/OperationNoteModel",
"version": "0.1.0",
"differential": {
"element": [ {
"id": "OperationNoteModel",
"path": "OperationNoteModel",
"short": "手術紀錄(OperationNote)之資料模型",
"mapping": [ {
"map": "BundleOperationNoteIMRI",
"identity": "OperationNote"
} ],
"definition": "手術紀錄(OperationNote)之資料模型"
}, {
"id": "OperationNoteModel.organization",
"max": "1",
"min": 1,
"path": "OperationNoteModel.organization",
"type": [ {
"code": "BackboneElement"
} ],
"short": "醫事機構",
"definition": "醫事機構"
}, {
"id": "OperationNoteModel.organization.identifier",
"max": "1",
"min": 1,
"path": "OperationNoteModel.organization.identifier",
"type": [ {
"code": "Identifier"
} ],
"short": "醫事機構代碼",
"mapping": [ {
"map": "entry:OrganizationHospIMRI.identifier",
"identity": "OperationNote"
} ],
"definition": "醫事機構代碼"
}, {
"id": "OperationNoteModel.organization.name",
"max": "1",
"min": 1,
"path": "OperationNoteModel.organization.name",
"type": [ {
"code": "string"
} ],
"short": "醫事機構名稱",
"mapping": [ {
"map": "entry:OrganizationHospIMRI.name",
"identity": "OperationNote"
} ],
"definition": "醫事機構名稱"
}, {
"id": "OperationNoteModel.patient",
"max": "1",
"min": 1,
"path": "OperationNoteModel.patient",
"type": [ {
"code": "BackboneElement"
} ],
"short": "病人的基本資料",
"definition": "病人的基本資料"
}, {
"id": "OperationNoteModel.patient.identifier",
"max": "1",
"min": 1,
"path": "OperationNoteModel.patient.identifier",
"type": [ {
"code": "Identifier"
} ],
"short": "身分證字號",
"mapping": [ {
"map": "entry:PatientIMRI.identifier:idCardNumber",
"identity": "OperationNote"
} ],
"definition": "身分證字號"
}, {
"id": "OperationNoteModel.patient.patientNo",
"max": "1",
"min": 1,
"path": "OperationNoteModel.patient.patientNo",
"type": [ {
"code": "Identifier"
} ],
"short": "病歷號碼",
"mapping": [ {
"map": "entry:PatientIMRI.identifier:medicalRecord",
"identity": "OperationNote"
} ],
"definition": "病歷號碼"
}, {
"id": "OperationNoteModel.patient.name",
"max": "*",
"min": 1,
"path": "OperationNoteModel.patient.name",
"type": [ {
"code": "HumanName"
} ],
"short": "姓名",
"mapping": [ {
"map": "entry:PatientIMRI.name",
"identity": "OperationNote"
} ],
"definition": "病人之合法姓名。"
}, {
"id": "OperationNoteModel.patient.gender",
"max": "1",
"min": 1,
"path": "OperationNoteModel.patient.gender",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "性別",
"mapping": [ {
"map": "entry:PatientIMRI.gender",
"identity": "OperationNote"
} ],
"definition": "性別"
}, {
"id": "OperationNoteModel.patient.birthDate",
"max": "1",
"min": 1,
"path": "OperationNoteModel.patient.birthDate",
"type": [ {
"code": "dateTime"
} ],
"short": "出生日期",
"mapping": [ {
"map": "entry:PatientIMRI.birthDate",
"identity": "OperationNote"
} ],
"definition": "病人的生日，如果有完整或部分的生日日期則必須提供，若無完整或部分的生日日期則以空字串''表示之。"
}, {
"id": "OperationNoteModel.patient.bloodtype",
"max": "1",
"min": 0,
"path": "OperationNoteModel.patient.bloodtype",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "血型",
"mapping": [ {
"map": "entry:ObservationBloodTypeIMRI.valueCodeableConcept",
"identity": "OperationNote"
} ],
"definition": "血型"
}, {
"id": "OperationNoteModel.operation",
"max": "1",
"min": 1,
"path": "OperationNoteModel.operation",
"type": [ {
"code": "BackboneElement"
} ],
"short": "手術資料",
"definition": "手術資料"
}, {
"id": "OperationNoteModel.operation.operationDateTime",
"max": "1",
"min": 1,
"path": "OperationNoteModel.operation.operationDateTime",
"type": [ {
"code": "dateTime"
} ],
"short": "手術日期時間",
"mapping": [ {
"map": "entry:ProcedureOperationIMRI.performedDateTime",
"identity": "OperationNote"
} ],
"definition": "手術日期時間"
}, {
"id": "OperationNoteModel.operation.preoperativeDiagnosis",
"max": "*",
"min": 1,
"path": "OperationNoteModel.operation.preoperativeDiagnosis",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "手術前診斷",
"mapping": [ {
"map": "entry:ProcedureOperationIMRI.reasonReference.Reference(TWCoreCondition).code.coding.code",
"identity": "OperationNote"
} ],
"definition": "手術前診斷"
}, {
"id": "OperationNoteModel.operation.postoperativeDiagnosis[x]",
"max": "*",
"min": 0,
"path": "OperationNoteModel.operation.postoperativeDiagnosis[x]",
"type": [ {
"code": "Narrative"
}, {
"code": "CodeableConcept"
} ],
"short": "手術後診斷",
"mapping": [ {
"map": "entry:CompositionOperationNoteIMRI.section:OperationNote.section:postoperativeDiagnosis.text 或 entry:TWCoreCondition.code.coding.code",
"identity": "OperationNote"
} ],
"definition": "手術後診斷"
}, {
"id": "OperationNoteModel.operation.operationCode",
"max": "1",
"min": 1,
"path": "OperationNoteModel.operation.operationCode",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "手術代碼",
"mapping": [ {
"map": "entry:ProcedureOperationIMRI.code.coding.code",
"identity": "OperationNote"
} ],
"definition": "手術代碼"
}, {
"id": "OperationNoteModel.operation.bodyPart",
"max": "*",
"min": 0,
"path": "OperationNoteModel.operation.bodyPart",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "手術部位",
"mapping": [ {
"map": "entry:ProcedureOperationIMRI.bodySite",
"identity": "OperationNote"
} ],
"definition": "手術部位"
}, {
"id": "OperationNoteModel.operation.indication",
"max": "1",
"min": 1,
"path": "OperationNoteModel.operation.indication",
"type": [ {
"code": "string"
} ],
"short": "手術目的",
"mapping": [ {
"map": "entry:ProcedureOperationIMRI.code.coding.display",
"identity": "OperationNote"
} ],
"definition": "手術目的"
}, {
"id": "OperationNoteModel.operation.bloodLoss[x]",
"max": "1",
"min": 0,
"path": "OperationNoteModel.operation.bloodLoss[x]",
"type": [ {
"code": "Narrative"
}, {
"code": "decimal"
} ],
"short": "失血量",
"mapping": [ {
"map": "entry:CompositionOperationNoteIMRI.section:OperationNote.section:bloodLoss.text 或 entry:ObservationBloodLossIMRI.valueQuantity.value",
"identity": "OperationNote"
} ],
"definition": "失血量"
}, {
"id": "OperationNoteModel.operation.anesthesiaMode[x]",
"max": "1",
"min": 0,
"path": "OperationNoteModel.operation.anesthesiaMode[x]",
"type": [ {
"code": "Narrative"
}, {
"code": "CodeableConcept"
} ],
"short": "麻醉模式",
"mapping": [ {
"map": "entry:CompositionOperationNoteIMRI.section:OperationNote.section:anesthesiaMode.text 或 entry:ProcedureAnesthesiaModeIMRI.code",
"identity": "OperationNote"
} ],
"definition": "麻醉模式"
}, {
"id": "OperationNoteModel.operation.anesthesiologist",
"max": "*",
"min": 0,
"path": "OperationNoteModel.operation.anesthesiologist",
"type": [ {
"code": "HumanName"
} ],
"short": "麻醉醫師",
"mapping": [ {
"map": "entry:ProcedureAnesthesiaModeIMRI.performer.actor.Reference(PractitionerRoleIMRI).where(code = '88189002').practitioner.Reference(PractitionerIMRI).name",
"identity": "OperationNote"
} ],
"definition": "麻醉醫師"
}, {
"id": "OperationNoteModel.operation.operativeFinding",
"max": "*",
"min": 1,
"path": "OperationNoteModel.operation.operativeFinding",
"type": [ {
"code": "markdown"
} ],
"short": "手術發現",
"mapping": [ {
"map": "entry:ProcedureOperationIMRI.note[0].text",
"identity": "OperationNote"
} ],
"definition": "手術發現"
}, {
"id": "OperationNoteModel.operation.operationProcedure",
"max": "*",
"min": 1,
"path": "OperationNoteModel.operation.operationProcedure",
"type": [ {
"code": "markdown"
} ],
"short": "手術過程紀錄",
"mapping": [ {
"map": "entry:ProcedureOperationIMRI.note[1].text",
"identity": "OperationNote"
} ],
"definition": "手術過程紀錄"
}, {
"id": "OperationNoteModel.operation.device",
"max": "*",
"min": 0,
"path": "OperationNoteModel.operation.device",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "手術特材",
"mapping": [ {
"map": "entry:ProcedureOperationIMRI.usedCode",
"identity": "OperationNote"
} ],
"definition": "手術特材"
}, {
"id": "OperationNoteModel.operation.surgeon",
"max": "*",
"min": 0,
"path": "OperationNoteModel.operation.surgeon",
"type": [ {
"code": "HumanName"
} ],
"short": "手術醫師",
"mapping": [ {
"map": "entry:ProcedureOperationIMRI.performer.actor.Reference(PractitionerRoleIMRI).where(code = '304292004').practitioner.Reference(PractitionerIMRI).name",
"identity": "OperationNote"
} ],
"definition": "手術醫師"
}, {
"id": "OperationNoteModel.operation.surgicalImage",
"max": "*",
"min": 0,
"path": "OperationNoteModel.operation.surgicalImage",
"type": [ {
"code": "url"
} ],
"short": "手術圖像",
"mapping": [ {
"map": "entry:ProcedureOperationIMRI.report.Reference(TWCoreDocumentReference).content.attachment.url",
"identity": "OperationNote"
} ],
"definition": "手術圖像"
} ]
},
"contact": [ {
"name": "國泰金控",
"telecom": [ {
"value": "https://www.cathayholdings.com/holdings/",
"system": "url"
} ]
} ],
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/Base"
}