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: 出院小结共享文档本地化定义

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

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 Composition

Summary

Mandatory: 13 elements (1 nested mandatory element)
Must-Support: 4 elements

Slices

This structure defines the following Slices:

  • The element Composition.section is sliced based on the value of type:resource

这种结构源自 Composition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... identifier 1..1Identifier文档的业务标识符
... status 1..1code文档的状态
... type 1..1CodeableConcept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
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org.cn/fhir/CodeSystem/emr-document-type
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: C0053
..... display1..1stringRepresentation defined by the system
Fixed Value: 出院小结
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org.cn/fhir/CodeSystem/document-category
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: EMR
..... display1..1stringRepresentation defined by the system
Fixed Value: 电子病历共享文档
... subject 1..1Reference(Patient)指向住院患者
... encounter 1..1Reference(Encounter)指向记录本次住院活动的就诊资源
... date 1..1dateTime文档的生成时间
... author 1..1Reference(Practitioner)文档的作者，指向患者的主治医师
... title 1..1string文档的标题
Required Pattern: 出院小结
... custodian 1..1Reference(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..1string章节标题
..... code 1..1CodeableConcept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 S1..1BackboneElementComposition is broken into sections
..... title 0..1stringLabel for section (e.g. for ToC)
Required Pattern: 入院原因
..... code 0..1CodeableConceptClassification of section (recommended)
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://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 29299-5
....... display1..1stringRepresentation defined by the system
Fixed Value: Reason for visit
..... entry 1..*Reference(Observation)指向症状资源
.... section:Diagnosis S1..1BackboneElementComposition is broken into sections
..... title 0..1stringLabel for section (e.g. for ToC)
Required Pattern: 出院诊断
..... code 0..1CodeableConceptClassification of section (recommended)
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://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11535-2
....... display1..1stringRepresentation defined by the system
Fixed Value: Hospital discharge diagnosis
..... entry 1..*Reference(Condition)指向诊断资源
.... section:Medications S1..1BackboneElementComposition is broken into sections
..... title 0..1stringLabel for section (e.g. for ToC)
Required Pattern: 出院用药
..... code 0..1CodeableConceptClassification of section (recommended)
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://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10183-2
....... display1..1stringRepresentation defined by the system
Fixed Value: Hospital discharge medications
..... entry 1..*Reference(MedicationRequest)指向药物请求资源
.... section:Allergies S0..1BackboneElementComposition is broken into sections
..... title 0..1stringLabel for section (e.g. for ToC)
Required Pattern: 过敏和不良反应
..... code 0..1CodeableConceptClassification of section (recommended)
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://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 48765-2
....... display1..1stringRepresentation 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

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... 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
... language 0..1codeLanguage of the resource content
Binding: AllLanguages (required): IETF language tag for a human language

Additional BindingsPurpose
CommonLanguagesStarter Set
... 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
... url Σ0..1uriCanonical identifier for this Composition, represented as a URI (globally unique)
... identifier Σ1..1Identifier文档的业务标识符
... version Σ0..1stringAn explicitly assigned identifer of a variation of the content in the Composition
... status ?!Σ1..1code文档的状态
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... type Σ1..1CodeableConcept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
.... 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://hl7.org.cn/fhir/CodeSystem/emr-document-type
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: C0053
..... display1..1stringRepresentation defined by the system
Fixed Value: 出院小结
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... category Σ1..1CodeableConcept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
.... 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://hl7.org.cn/fhir/CodeSystem/document-category
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: EMR
..... display1..1stringRepresentation defined by the system
Fixed Value: 电子病历共享文档
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... subject Σ1..1Reference(Patient)指向住院患者
... encounter Σ1..1Reference(Encounter)指向记录本次住院活动的就诊资源
... date Σ1..1dateTime文档的生成时间
... useContext Σ0..*UsageContextThe context that the content is intended to support
... author Σ1..1Reference(Practitioner)文档的作者，指向患者的主治医师
... name Σ0..1stringName for this Composition (computer friendly)
... title Σ1..1string文档的标题
Required Pattern: 出院小结
... note 0..*AnnotationFor any additional notes
... attester 0..*BackboneElementAttests to accuracy of composition
.... 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
.... mode 1..1CodeableConceptpersonal | professional | legal | official
Binding: CompositionAttestationMode (preferred): The way in which a person authenticated a composition.

.... time 0..1dateTimeWhen the composition was attested
.... party 0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Who attested the composition
... custodian Σ1..1Reference(Organization)文档所属管理机构，一般为患者的就诊机构。
... relatesTo 0..*RelatedArtifactRelationships to other compositions/documents
... event Σ0..*BackboneElementThe clinical service(s) being documented
.... 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
.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*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 C3..*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..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1string章节标题
..... code 1..1CodeableConcept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..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry C0..*Reference(Resource)章节所包含的条目，指向一个资源
..... emptyReason C0..1CodeableConceptWhy 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 SC1..1BackboneElementComposition 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..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
Required Pattern: 入院原因
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


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://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 29299-5
....... display1..1stringRepresentation defined by the system
Fixed Value: Reason for visit
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry C1..*Reference(Observation)指向症状资源
..... emptyReason C0..1CodeableConceptWhy 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 SC1..1BackboneElementComposition 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..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
Required Pattern: 出院诊断
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


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://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11535-2
....... display1..1stringRepresentation defined by the system
Fixed Value: Hospital discharge diagnosis
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry C1..*Reference(Condition)指向诊断资源
..... emptyReason C0..1CodeableConceptWhy 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 SC1..1BackboneElementComposition 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..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
Required Pattern: 出院用药
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


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://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10183-2
....... display1..1stringRepresentation defined by the system
Fixed Value: Hospital discharge medications
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry C1..*Reference(MedicationRequest)指向药物请求资源
..... emptyReason C0..1CodeableConceptWhy 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 SC0..1BackboneElementComposition 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..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
Required Pattern: 过敏和不良反应
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


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://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 48765-2
....... display1..1stringRepresentation defined by the system
Fixed Value: Allergies and adverse reactions
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry C1..*Reference(AllergyIntolerance)指向过敏和不良反应资源
..... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section 0..*See section (Composition)Nested Section

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... section:ReasonForVisit C1..1BackboneElementComposition 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 C1..1BackboneElementComposition 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 C1..1BackboneElementComposition 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

doco 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:

  • The element Composition.section is sliced based on the value of type:resource

差异视图

这种结构源自 Composition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... identifier 1..1Identifier文档的业务标识符
... status 1..1code文档的状态
... type 1..1CodeableConcept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
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org.cn/fhir/CodeSystem/emr-document-type
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: C0053
..... display1..1stringRepresentation defined by the system
Fixed Value: 出院小结
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org.cn/fhir/CodeSystem/document-category
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: EMR
..... display1..1stringRepresentation defined by the system
Fixed Value: 电子病历共享文档
... subject 1..1Reference(Patient)指向住院患者
... encounter 1..1Reference(Encounter)指向记录本次住院活动的就诊资源
... date 1..1dateTime文档的生成时间
... author 1..1Reference(Practitioner)文档的作者，指向患者的主治医师
... title 1..1string文档的标题
Required Pattern: 出院小结
... custodian 1..1Reference(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..1string章节标题
..... code 1..1CodeableConcept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 S1..1BackboneElementComposition is broken into sections
..... title 0..1stringLabel for section (e.g. for ToC)
Required Pattern: 入院原因
..... code 0..1CodeableConceptClassification of section (recommended)
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://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 29299-5
....... display1..1stringRepresentation defined by the system
Fixed Value: Reason for visit
..... entry 1..*Reference(Observation)指向症状资源
.... section:Diagnosis S1..1BackboneElementComposition is broken into sections
..... title 0..1stringLabel for section (e.g. for ToC)
Required Pattern: 出院诊断
..... code 0..1CodeableConceptClassification of section (recommended)
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://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11535-2
....... display1..1stringRepresentation defined by the system
Fixed Value: Hospital discharge diagnosis
..... entry 1..*Reference(Condition)指向诊断资源
.... section:Medications S1..1BackboneElementComposition is broken into sections
..... title 0..1stringLabel for section (e.g. for ToC)
Required Pattern: 出院用药
..... code 0..1CodeableConceptClassification of section (recommended)
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://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10183-2
....... display1..1stringRepresentation defined by the system
Fixed Value: Hospital discharge medications
..... entry 1..*Reference(MedicationRequest)指向药物请求资源
.... section:Allergies S0..1BackboneElementComposition is broken into sections
..... title 0..1stringLabel for section (e.g. for ToC)
Required Pattern: 过敏和不良反应
..... code 0..1CodeableConceptClassification of section (recommended)
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://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 48765-2
....... display1..1stringRepresentation 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

doco Documentation for this format

快照视图

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... 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
... language 0..1codeLanguage of the resource content
Binding: AllLanguages (required): IETF language tag for a human language

Additional BindingsPurpose
CommonLanguagesStarter Set
... 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
... url Σ0..1uriCanonical identifier for this Composition, represented as a URI (globally unique)
... identifier Σ1..1Identifier文档的业务标识符
... version Σ0..1stringAn explicitly assigned identifer of a variation of the content in the Composition
... status ?!Σ1..1code文档的状态
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... type Σ1..1CodeableConcept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
.... 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://hl7.org.cn/fhir/CodeSystem/emr-document-type
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: C0053
..... display1..1stringRepresentation defined by the system
Fixed Value: 出院小结
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... category Σ1..1CodeableConcept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
.... 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://hl7.org.cn/fhir/CodeSystem/document-category
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: EMR
..... display1..1stringRepresentation defined by the system
Fixed Value: 电子病历共享文档
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... subject Σ1..1Reference(Patient)指向住院患者
... encounter Σ1..1Reference(Encounter)指向记录本次住院活动的就诊资源
... date Σ1..1dateTime文档的生成时间
... useContext Σ0..*UsageContextThe context that the content is intended to support
... author Σ1..1Reference(Practitioner)文档的作者，指向患者的主治医师
... name Σ0..1stringName for this Composition (computer friendly)
... title Σ1..1string文档的标题
Required Pattern: 出院小结
... note 0..*AnnotationFor any additional notes
... attester 0..*BackboneElementAttests to accuracy of composition
.... 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
.... mode 1..1CodeableConceptpersonal | professional | legal | official
Binding: CompositionAttestationMode (preferred): The way in which a person authenticated a composition.

.... time 0..1dateTimeWhen the composition was attested
.... party 0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Who attested the composition
... custodian Σ1..1Reference(Organization)文档所属管理机构，一般为患者的就诊机构。
... relatesTo 0..*RelatedArtifactRelationships to other compositions/documents
... event Σ0..*BackboneElementThe clinical service(s) being documented
.... 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
.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*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 C3..*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..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1string章节标题
..... code 1..1CodeableConcept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..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry C0..*Reference(Resource)章节所包含的条目，指向一个资源
..... emptyReason C0..1CodeableConceptWhy 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 SC1..1BackboneElementComposition 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..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
Required Pattern: 入院原因
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


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://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 29299-5
....... display1..1stringRepresentation defined by the system
Fixed Value: Reason for visit
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry C1..*Reference(Observation)指向症状资源
..... emptyReason C0..1CodeableConceptWhy 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 SC1..1BackboneElementComposition 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..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
Required Pattern: 出院诊断
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


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://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11535-2
....... display1..1stringRepresentation defined by the system
Fixed Value: Hospital discharge diagnosis
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry C1..*Reference(Condition)指向诊断资源
..... emptyReason C0..1CodeableConceptWhy 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 SC1..1BackboneElementComposition 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..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
Required Pattern: 出院用药
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


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://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10183-2
....... display1..1stringRepresentation defined by the system
Fixed Value: Hospital discharge medications
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry C1..*Reference(MedicationRequest)指向药物请求资源
..... emptyReason C0..1CodeableConceptWhy 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 SC0..1BackboneElementComposition 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..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
Required Pattern: 过敏和不良反应
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


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://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 48765-2
....... display1..1stringRepresentation defined by the system
Fixed Value: Allergies and adverse reactions
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry C1..*Reference(AllergyIntolerance)指向过敏和不良反应资源
..... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section 0..*See section (Composition)Nested Section

doco Documentation for this format

 

本定义的其它表示法: Schematron

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.languagerequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages|5.0.0
from the FHIR Standard
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|5.0.0
from the FHIR Standard
Composition.typerequiredPattern: C0053("出院小结")
http://hl7.org.cn/fhir/ValueSet/emr-document-type
from this IG
Composition.categoryrequiredPattern: EMR("电子病历共享文档")
http://hl7.org.cn/fhir/ValueSet/document-category
from this IG
Composition.attester.modepreferredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode
from the FHIR Standard
Composition.event.detailexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.coderequiredDocSectionCodes
http://hl7.org.cn/fhir/ValueSet/doc-section-codes
from this IG
Composition.section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
from the FHIR Standard
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
from the FHIR Standard
Composition.section:ReasonForVisit.codeexamplePattern: LOINC code 29299-5("Reason for visit")
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:ReasonForVisit.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
from the FHIR Standard
Composition.section:ReasonForVisit.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
from the FHIR Standard
Composition.section:Diagnosis.codeexamplePattern: LOINC code 11535-2("Hospital discharge diagnosis")
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:Diagnosis.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
from the FHIR Standard
Composition.section:Diagnosis.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
from the FHIR Standard
Composition.section:Medications.codeexamplePattern: LOINC code 10183-2("Hospital discharge medications")
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:Medications.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
from the FHIR Standard
Composition.section:Medications.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
from the FHIR Standard
Composition.section:Allergies.codeexamplePattern: LOINC code 48765-2("Allergies and adverse reactions")
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:Allergies.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
from the FHIR Standard
Composition.section:Allergies.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.section, Composition.section:ReasonForVisit, Composition.section:Diagnosis, Composition.section:Medications, Composition.section:AllergiesA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.section, Composition.section:ReasonForVisit, Composition.section:Diagnosis, Composition.section:Medications, Composition.section:AllergiesA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf 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-4errorCompositionIf 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-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA 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()