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。
Defining URL: | http://hl7.org.cn/fhir/StructureDefinition/profile-discharge-summary-document |
Version: | 2024.5.5 |
Name: | DocumentDischargeSummary |
Title: | 出院小结共享文档本地化定义 |
Status: | Active as of 2024-05-05 21:11:47+0800 |
Definition: | 出院小结共享文档本地化定义。 |
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/profile-discharge-summary-document
这种结构源自 Composition
Summary
Mandatory: 13 elements (1 nested mandatory element)
Must-Support: 4 elements
Slices
This structure defines the following Slices:
这种结构源自 Composition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
identifier | 1..1 | Identifier | 文档的业务标识符 | |
status | 1..1 | code | 文档的状态 | |
type | 1..1 | CodeableConcept | 文档类型,由具体的文档定义指定其类型 Binding: 电子病历共享文档类型代码表 (required) 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://hl7.org.cn/fhir/CodeSystem/emr-document-type | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: C0053 | |
display | 1..1 | string | Representation defined by the system Fixed Value: 出院小结 | |
category | 1..1 | CodeableConcept | 文档的分类:EMR|EHR|PHR Binding: 共享文档类别代码表 (required) 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://hl7.org.cn/fhir/CodeSystem/document-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: EMR | |
display | 1..1 | string | Representation defined by the system Fixed Value: 电子病历共享文档 | |
subject | 1..1 | Reference(Patient) | 指向住院患者 | |
encounter | 1..1 | Reference(Encounter) | 指向记录本次住院活动的就诊资源 | |
date | 1..1 | dateTime | 文档的生成时间 | |
author | 1..1 | Reference(Practitioner) | 文档的作者,指向患者的主治医师 | |
title | 1..1 | string | 文档的标题 Required Pattern: 出院小结 | |
custodian | 1..1 | Reference(Organization) | 文档所属管理机构,一般为患者的就诊机构。 | |
Slices for section | 3..* | BackboneElement | 文档的具体章节 Slice: Unordered, Open by type:resource | |
section:All Slices | Content/Rules for all slices | |||
title | 1..1 | string | 章节标题 | |
code | 1..1 | CodeableConcept | 章节的编码表示 Binding: 共享文档章节代码表 (required) | |
entry | 0..* | Reference(Resource) | 章节所包含的条目,指向一个资源 | |
section:ReasonForVisit | S | 1..1 | BackboneElement | Composition is broken into sections |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: 入院原因 | |
code | 0..1 | CodeableConcept | Classification of section (recommended) 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29299-5 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Reason for visit | |
entry | 1..* | Reference(Observation) | 指向症状资源 | |
section:Diagnosis | S | 1..1 | BackboneElement | Composition is broken into sections |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: 出院诊断 | |
code | 0..1 | CodeableConcept | Classification of section (recommended) 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11535-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital discharge diagnosis | |
entry | 1..* | Reference(Condition) | 指向诊断资源 | |
section:Medications | S | 1..1 | BackboneElement | Composition is broken into sections |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: 出院用药 | |
code | 0..1 | CodeableConcept | Classification of section (recommended) 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10183-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital discharge medications | |
entry | 1..* | Reference(MedicationRequest) | 指向药物请求资源 | |
section:Allergies | S | 0..1 | BackboneElement | Composition is broken into sections |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: 过敏和不良反应 | |
code | 0..1 | CodeableConcept | Classification of section (recommended) 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Allergies and adverse reactions | |
entry | 1..* | Reference(AllergyIntolerance) | 指向过敏和不良反应资源 | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: AllLanguages (required): IETF language tag for a human language
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
url | Σ | 0..1 | uri | Canonical identifier for this Composition, represented as a URI (globally unique) | ||||
identifier | Σ | 1..1 | Identifier | 文档的业务标识符 | ||||
version | Σ | 0..1 | string | An explicitly assigned identifer of a variation of the content in the Composition | ||||
status | ?!Σ | 1..1 | code | 文档的状态 Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
type | Σ | 1..1 | CodeableConcept | 文档类型,由具体的文档定义指定其类型 Binding: 电子病历共享文档类型代码表 (required) 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://hl7.org.cn/fhir/CodeSystem/emr-document-type | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: C0053 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: 出院小结 | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
category | Σ | 1..1 | CodeableConcept | 文档的分类:EMR|EHR|PHR Binding: 共享文档类别代码表 (required) 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://hl7.org.cn/fhir/CodeSystem/document-category | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: EMR | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: 电子病历共享文档 | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
subject | Σ | 1..1 | Reference(Patient) | 指向住院患者 | ||||
encounter | Σ | 1..1 | Reference(Encounter) | 指向记录本次住院活动的就诊资源 | ||||
date | Σ | 1..1 | dateTime | 文档的生成时间 | ||||
useContext | Σ | 0..* | UsageContext | The context that the content is intended to support | ||||
author | Σ | 1..1 | Reference(Practitioner) | 文档的作者,指向患者的主治医师 | ||||
name | Σ | 0..1 | string | Name for this Composition (computer friendly) | ||||
title | Σ | 1..1 | string | 文档的标题 Required Pattern: 出院小结 | ||||
note | 0..* | Annotation | For any additional notes | |||||
attester | 0..* | BackboneElement | Attests to accuracy of composition | |||||
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 | ||||
mode | 1..1 | CodeableConcept | personal | professional | legal | official Binding: CompositionAttestationMode (preferred): The way in which a person authenticated a composition. | |||||
time | 0..1 | dateTime | When the composition was attested | |||||
party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
custodian | Σ | 1..1 | Reference(Organization) | 文档所属管理机构,一般为患者的就诊机构。 | ||||
relatesTo | 0..* | RelatedArtifact | Relationships to other compositions/documents | |||||
event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
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 | ||||
period | Σ | 0..1 | Period | The period covered by the documentation | ||||
detail | Σ | 0..* | CodeableReference(Resource) | The event(s) being documented, as code(s), reference(s), or both Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
Slices for section | C | 3..* | BackboneElement | 文档的具体章节 Slice: Unordered, Open by type:resource cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
section:All Slices | Content/Rules for all slices | |||||||
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 | ||||
title | 1..1 | string | 章节标题 | |||||
code | 1..1 | CodeableConcept | 章节的编码表示 Binding: 共享文档章节代码表 (required) | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | 章节所包含的条目,指向一个资源 | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | 0..* | See section (Composition) | Nested Section | |||||
section:ReasonForVisit | SC | 1..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | ||||
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: 入院原因 | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29299-5 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Reason for visit | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Observation) | 指向症状资源 | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | 0..* | See section (Composition) | Nested Section | |||||
section:Diagnosis | SC | 1..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | ||||
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: 出院诊断 | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11535-2 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital discharge diagnosis | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Condition) | 指向诊断资源 | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | 0..* | See section (Composition) | Nested Section | |||||
section:Medications | SC | 1..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | ||||
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: 出院用药 | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10183-2 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital discharge medications | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(MedicationRequest) | 指向药物请求资源 | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | 0..* | See section (Composition) | Nested Section | |||||
section:Allergies | SC | 0..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | ||||
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: 过敏和不良反应 | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Allergies and adverse reactions | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(AllergyIntolerance) | 指向过敏和不良反应资源 | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | 0..* | See section (Composition) | Nested Section | |||||
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
section:ReasonForVisit | C | 1..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
section:Diagnosis | C | 1..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
section:Medications | C | 1..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
section:Allergies | C | 0..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
Documentation for this format |
这种结构源自 Composition
Summary
Mandatory: 13 elements (1 nested mandatory element)
Must-Support: 4 elements
Slices
This structure defines the following Slices:
差异视图
这种结构源自 Composition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
identifier | 1..1 | Identifier | 文档的业务标识符 | |
status | 1..1 | code | 文档的状态 | |
type | 1..1 | CodeableConcept | 文档类型,由具体的文档定义指定其类型 Binding: 电子病历共享文档类型代码表 (required) 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://hl7.org.cn/fhir/CodeSystem/emr-document-type | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: C0053 | |
display | 1..1 | string | Representation defined by the system Fixed Value: 出院小结 | |
category | 1..1 | CodeableConcept | 文档的分类:EMR|EHR|PHR Binding: 共享文档类别代码表 (required) 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://hl7.org.cn/fhir/CodeSystem/document-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: EMR | |
display | 1..1 | string | Representation defined by the system Fixed Value: 电子病历共享文档 | |
subject | 1..1 | Reference(Patient) | 指向住院患者 | |
encounter | 1..1 | Reference(Encounter) | 指向记录本次住院活动的就诊资源 | |
date | 1..1 | dateTime | 文档的生成时间 | |
author | 1..1 | Reference(Practitioner) | 文档的作者,指向患者的主治医师 | |
title | 1..1 | string | 文档的标题 Required Pattern: 出院小结 | |
custodian | 1..1 | Reference(Organization) | 文档所属管理机构,一般为患者的就诊机构。 | |
Slices for section | 3..* | BackboneElement | 文档的具体章节 Slice: Unordered, Open by type:resource | |
section:All Slices | Content/Rules for all slices | |||
title | 1..1 | string | 章节标题 | |
code | 1..1 | CodeableConcept | 章节的编码表示 Binding: 共享文档章节代码表 (required) | |
entry | 0..* | Reference(Resource) | 章节所包含的条目,指向一个资源 | |
section:ReasonForVisit | S | 1..1 | BackboneElement | Composition is broken into sections |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: 入院原因 | |
code | 0..1 | CodeableConcept | Classification of section (recommended) 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29299-5 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Reason for visit | |
entry | 1..* | Reference(Observation) | 指向症状资源 | |
section:Diagnosis | S | 1..1 | BackboneElement | Composition is broken into sections |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: 出院诊断 | |
code | 0..1 | CodeableConcept | Classification of section (recommended) 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11535-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital discharge diagnosis | |
entry | 1..* | Reference(Condition) | 指向诊断资源 | |
section:Medications | S | 1..1 | BackboneElement | Composition is broken into sections |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: 出院用药 | |
code | 0..1 | CodeableConcept | Classification of section (recommended) 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10183-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital discharge medications | |
entry | 1..* | Reference(MedicationRequest) | 指向药物请求资源 | |
section:Allergies | S | 0..1 | BackboneElement | Composition is broken into sections |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: 过敏和不良反应 | |
code | 0..1 | CodeableConcept | Classification of section (recommended) 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Allergies and adverse reactions | |
entry | 1..* | Reference(AllergyIntolerance) | 指向过敏和不良反应资源 | |
Documentation for this format |
快照视图
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: AllLanguages (required): IETF language tag for a human language
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
url | Σ | 0..1 | uri | Canonical identifier for this Composition, represented as a URI (globally unique) | ||||
identifier | Σ | 1..1 | Identifier | 文档的业务标识符 | ||||
version | Σ | 0..1 | string | An explicitly assigned identifer of a variation of the content in the Composition | ||||
status | ?!Σ | 1..1 | code | 文档的状态 Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
type | Σ | 1..1 | CodeableConcept | 文档类型,由具体的文档定义指定其类型 Binding: 电子病历共享文档类型代码表 (required) 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://hl7.org.cn/fhir/CodeSystem/emr-document-type | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: C0053 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: 出院小结 | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
category | Σ | 1..1 | CodeableConcept | 文档的分类:EMR|EHR|PHR Binding: 共享文档类别代码表 (required) 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://hl7.org.cn/fhir/CodeSystem/document-category | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: EMR | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: 电子病历共享文档 | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
subject | Σ | 1..1 | Reference(Patient) | 指向住院患者 | ||||
encounter | Σ | 1..1 | Reference(Encounter) | 指向记录本次住院活动的就诊资源 | ||||
date | Σ | 1..1 | dateTime | 文档的生成时间 | ||||
useContext | Σ | 0..* | UsageContext | The context that the content is intended to support | ||||
author | Σ | 1..1 | Reference(Practitioner) | 文档的作者,指向患者的主治医师 | ||||
name | Σ | 0..1 | string | Name for this Composition (computer friendly) | ||||
title | Σ | 1..1 | string | 文档的标题 Required Pattern: 出院小结 | ||||
note | 0..* | Annotation | For any additional notes | |||||
attester | 0..* | BackboneElement | Attests to accuracy of composition | |||||
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 | ||||
mode | 1..1 | CodeableConcept | personal | professional | legal | official Binding: CompositionAttestationMode (preferred): The way in which a person authenticated a composition. | |||||
time | 0..1 | dateTime | When the composition was attested | |||||
party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
custodian | Σ | 1..1 | Reference(Organization) | 文档所属管理机构,一般为患者的就诊机构。 | ||||
relatesTo | 0..* | RelatedArtifact | Relationships to other compositions/documents | |||||
event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
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 | ||||
period | Σ | 0..1 | Period | The period covered by the documentation | ||||
detail | Σ | 0..* | CodeableReference(Resource) | The event(s) being documented, as code(s), reference(s), or both Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
Slices for section | C | 3..* | BackboneElement | 文档的具体章节 Slice: Unordered, Open by type:resource cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
section:All Slices | Content/Rules for all slices | |||||||
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 | ||||
title | 1..1 | string | 章节标题 | |||||
code | 1..1 | CodeableConcept | 章节的编码表示 Binding: 共享文档章节代码表 (required) | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | 章节所包含的条目,指向一个资源 | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | 0..* | See section (Composition) | Nested Section | |||||
section:ReasonForVisit | SC | 1..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | ||||
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: 入院原因 | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29299-5 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Reason for visit | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Observation) | 指向症状资源 | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | 0..* | See section (Composition) | Nested Section | |||||
section:Diagnosis | SC | 1..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | ||||
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: 出院诊断 | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11535-2 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital discharge diagnosis | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Condition) | 指向诊断资源 | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | 0..* | See section (Composition) | Nested Section | |||||
section:Medications | SC | 1..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | ||||
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: 出院用药 | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10183-2 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital discharge medications | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(MedicationRequest) | 指向药物请求资源 | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | 0..* | See section (Composition) | Nested Section | |||||
section:Allergies | SC | 0..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | ||||
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: 过敏和不良反应 | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Allergies and adverse reactions | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(AllergyIntolerance) | 指向过敏和不良反应资源 | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | 0..* | See section (Composition) | Nested Section | |||||
Documentation for this format |