HL7中国FHIR Connectathon测试实施指南
2024.5.5 - release

本指南适用于HL7中国的FHIR Connectathon测试。

Resource Profile: 诊断结构定义

Defining URL:http://hl7.org.cn/fhir/StructureDefinition/core-diagnosis
Version:2024.5.5
Name:CoreDiagnosis
Title:诊断结构定义
Status:Active as of 2024-05-05 21:11:47+0800
Definition:

诊断本地化定义。

Publisher:HL7中国. HL7中国,
Source Resource:XML / JSON / Turtle

本定义的正式URL为: 

http://hl7.org.cn/fhir/StructureDefinition/core-diagnosis

定义内容的视图

关于定义、差异、快照以及如何解读这些表示法。

这种结构源自 Condition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*ConditionDetailed information about conditions, problems or diagnoses
... clinicalStatus 1..1CodeableConcept记录诊断的临床状态。例如：活跃、不活跃、已解决等
... category 1..1CodeableConcept记录诊断的分类
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: encounter-diagnosis
..... display1..1stringRepresentation defined by the system
Fixed Value: 诊断
... code 1..1CodeableConcept诊断的编码
Binding: http://hl7.org/fhir/sid/icd-10 (preferred)
... encounter 1..1Reference(门诊就诊服务结构定义 | 住院就诊服务结构定义)指向诊疗活动资源，例如：随访、门诊、住院等
... onset[x] 0..1dateTimeEstimated or actual date, date-time, or age
Slice: Unordered, Open by type:$this
... onsetDateTime 0..1dateTime诊断开始时间，可以是估计时间
... participant 1..*BackboneElement问题记录医师
.... actor 1..1Reference(卫生服务人员信息结构定义)Who or what participated in the activities related to the condition
... note 0..*Annotation关于该症状的附加信息

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*ConditionDetailed information about conditions, problems or diagnoses
con-2: If category is problems list item, the clinicalStatus should not be unknown
con-3: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission.
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!ΣC1..1CodeableConcept记录诊断的临床状态。例如：活跃、不活跃、已解决等
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

... verificationStatus ?!Σ0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.

... category C1..1CodeableConcept记录诊断的分类
Binding: ConditionCategoryCodes (preferred): A category assigned to the condition.



Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: encounter-diagnosis
..... display1..1stringRepresentation defined by the system
Fixed Value: 诊断
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... severity 0..1CodeableConceptSubjective severity of condition
Binding: ConditionDiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.

... code Σ1..1CodeableConcept诊断的编码
Binding: http://hl7.org/fhir/sid/icd-10 (preferred)
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): SNOMED CT Body site concepts


... subject Σ1..1Reference(患者信息结构定义)指向患者的引用
... encounter Σ1..1Reference(门诊就诊服务结构定义 | 住院就诊服务结构定义)指向诊疗活动资源，例如：随访、门诊、住院等
... Slices for onset[x] Σ0..1dateTimeEstimated or actual date, date-time, or age
Slice: Unordered, Closed by type:$this
.... onset[x]:onsetDateTime Σ0..1dateTime诊断开始时间，可以是估计时间
... abatement[x] C0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... recordedDate Σ0..1dateTimeDate condition was first recorded
... participant Σ1..*BackboneElement问题记录医师
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... function Σ0..1CodeableConceptType of involvement
Binding: ParticipationRoleType (extensible)
.... actor Σ1..1Reference(卫生服务人员信息结构定义)Who or what participated in the activities related to the condition
... stage C0..*BackboneElementStage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... summary C0..1CodeableConceptSimple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).

.... assessment C0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
.... type 0..1CodeableConceptKind of staging
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).

... evidence Σ0..*CodeableReference(Resource)Supporting evidence for the verification status
Binding: SNOMEDCTClinicalFindings (example)
... note 0..*Annotation关于该症状的附加信息

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*ConditionDetailed information about conditions, problems or diagnoses

doco Documentation for this format

差异视图

这种结构源自 Condition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*ConditionDetailed information about conditions, problems or diagnoses
... clinicalStatus 1..1CodeableConcept记录诊断的临床状态。例如：活跃、不活跃、已解决等
... category 1..1CodeableConcept记录诊断的分类
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: encounter-diagnosis
..... display1..1stringRepresentation defined by the system
Fixed Value: 诊断
... code 1..1CodeableConcept诊断的编码
Binding: http://hl7.org/fhir/sid/icd-10 (preferred)
... encounter 1..1Reference(门诊就诊服务结构定义 | 住院就诊服务结构定义)指向诊疗活动资源，例如：随访、门诊、住院等
... onset[x] 0..1dateTimeEstimated or actual date, date-time, or age
Slice: Unordered, Open by type:$this
... onsetDateTime 0..1dateTime诊断开始时间，可以是估计时间
... participant 1..*BackboneElement问题记录医师
.... actor 1..1Reference(卫生服务人员信息结构定义)Who or what participated in the activities related to the condition
... note 0..*Annotation关于该症状的附加信息

doco Documentation for this format

快照视图

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*ConditionDetailed information about conditions, problems or diagnoses
con-2: If category is problems list item, the clinicalStatus should not be unknown
con-3: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission.
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!ΣC1..1CodeableConcept记录诊断的临床状态。例如：活跃、不活跃、已解决等
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

... verificationStatus ?!Σ0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.

... category C1..1CodeableConcept记录诊断的分类
Binding: ConditionCategoryCodes (preferred): A category assigned to the condition.



Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: encounter-diagnosis
..... display1..1stringRepresentation defined by the system
Fixed Value: 诊断
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... severity 0..1CodeableConceptSubjective severity of condition
Binding: ConditionDiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.

... code Σ1..1CodeableConcept诊断的编码
Binding: http://hl7.org/fhir/sid/icd-10 (preferred)
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): SNOMED CT Body site concepts


... subject Σ1..1Reference(患者信息结构定义)指向患者的引用
... encounter Σ1..1Reference(门诊就诊服务结构定义 | 住院就诊服务结构定义)指向诊疗活动资源，例如：随访、门诊、住院等
... Slices for onset[x] Σ0..1dateTimeEstimated or actual date, date-time, or age
Slice: Unordered, Closed by type:$this
.... onset[x]:onsetDateTime Σ0..1dateTime诊断开始时间，可以是估计时间
... abatement[x] C0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... recordedDate Σ0..1dateTimeDate condition was first recorded
... participant Σ1..*BackboneElement问题记录医师
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... function Σ0..1CodeableConceptType of involvement
Binding: ParticipationRoleType (extensible)
.... actor Σ1..1Reference(卫生服务人员信息结构定义)Who or what participated in the activities related to the condition
... stage C0..*BackboneElementStage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... summary C0..1CodeableConceptSimple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).

.... assessment C0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
.... type 0..1CodeableConceptKind of staging
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).

... evidence Σ0..*CodeableReference(Resource)Supporting evidence for the verification status
Binding: SNOMEDCTClinicalFindings (example)
... note 0..*Annotation关于该症状的附加信息

doco Documentation for this format

 

本定义的其它表示法: Schematron

Terminology Bindings

PathConformanceValueSet / CodeURI
Condition.languagerequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages|5.0.0
from the FHIR Standard
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical|5.0.0
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status|5.0.0
from the FHIR Standard
Condition.categorypreferredPattern: encounter-diagnosis("诊断")
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severitypreferredConditionDiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codepreferredhttp://hl7.org/fhir/sid/icd-10
http://hl7.org/fhir/sid/icd-10
Condition.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Condition.participant.functionextensibleParticipationRoleType
http://hl7.org/fhir/ValueSet/participation-role-type
from the FHIR Standard
Condition.stage.summaryexampleConditionStage
http://hl7.org/fhir/ValueSet/condition-stage
from the FHIR Standard
Condition.stage.typeexampleConditionStageType
http://hl7.org/fhir/ValueSet/condition-stage-type
from the FHIR Standard
Condition.evidenceexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
con-1errorCondition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
con-2warningConditionIf category is problems list item, the clinicalStatus should not be unknown
: category.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-category' and code='problem-list-item').exists() implies clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and code='unknown').exists().not()
con-3errorConditionIf condition is abated, then clinicalStatus must be either inactive, resolved, or remission.
: abatement.exists() implies (clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='inactive' or code='resolved' or code='remission')).exists())
dom-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorConditionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorConditionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceConditionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()