基于FHIR标准的健康档案共享文档实施指南
0.8.0.2022705 - 持续集成版
基于FHIR标准的健康档案共享文档实施指南
0.8.0.2022705 - 持续集成版
基于FHIR的健康档案共享文档实施时必须严格遵循本实施指南的规定。
@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <http://loinc.org/rdf#> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:Composition;
fhir:nodeRole fhir:treeRoot;
fhir:Resource.id [ fhir:value "HSDB0401CompositionExample01"];
fhir:Resource.meta [
fhir:Meta.profile [
fhir:value "http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-document-hsdb04-01";
fhir:index 0;
fhir:link <http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-document-hsdb04-01> ]
];
fhir:DomainResource.text [
fhir:Narrative.status [ fhir:value "generated" ];
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>identifier</b>: id: N123455</p><p><b>status</b>: final</p><p><b>type</b>: <span title=\"Codes: {http://hl7.org.cn/fhir/sd/ehr/CodeSystem/ehr-document-type HSDB04.01}\">高血压患者随访服务</span></p><p><b>category</b>: <span title=\"Codes: {http://hl7.org.cn/fhir/sd/ehr/CodeSystem/document-category EHR}\">电子健康档案共享文档</span></p><p><b>encounter</b>: <a href=\"Encounter-FollowupEncounterExample01.html\">Generated Summary: id: N1233456671; status: finished; <span title=\"{http://terminology.hl7.org/CodeSystem/v3-ActCode HH}\">随访</span>; <span title=\"Codes: {http://hl7.org.cn/fhir/sd/ehr/CodeSystem/cv06-00-207 2}\">家庭</span>; period: 2021-5-7 12:30:02 --> 2002-8-20 16:45:50</a></p><p><b>date</b>: 2002-8-24 5:45:50</p><p><b>author</b>: <a href=\"Practitioner-PractitionerExample01.html\">赵勇. Generated Summary: 赵勇; gender: male</a></p><p><b>title</b>: 高血压患者随访服务记录</p><p><b>confidentiality</b>: N</p><p><b>custodian</b>: <a href=\"Organization-OrganizationExample01.html\">北大人民医院. Generated Summary: id: 123321 (OFFICIAL); active; <span title=\"Codes: {http://hl7.org.cn/fhir/sd/ehr/CodeSystem/ws218-2002 A100}\">综合医院</span>, <span title=\"Codes: {http://hl7.org.cn/fhir/sd/ehr/CodeSystem/gb12402-2000 11}\">国有全资</span>, <span title=\"Codes: {http://hl7.org.cn/fhir/sd/ehr/CodeSystem/hospital-administration-level 2}\">市级</span>; name: 北大国际医院; Phone: 13111222121</a></p></div>"
];
fhir:Composition.identifier [
fhir:Identifier.system [ fhir:value "urn:oid:1.2.10093.1.23.24.3454354" ];
fhir:Identifier.value [ fhir:value "N123455" ]
];
fhir:Composition.status [ fhir:value "final"];
fhir:Composition.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org.cn/fhir/sd/ehr/CodeSystem/ehr-document-type" ];
fhir:Coding.code [ fhir:value "HSDB04.01" ];
fhir:Coding.display [ fhir:value "高血压患者随访服务" ] ]
];
fhir:Composition.category [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org.cn/fhir/sd/ehr/CodeSystem/document-category" ];
fhir:Coding.code [ fhir:value "EHR" ];
fhir:Coding.display [ fhir:value "电子健康档案共享文档" ] ]
];
fhir:Composition.subject [
fhir:Reference.reference [ fhir:value "Patient/PatientExample01" ];
fhir:Reference.display [ fhir:value "张三" ]
];
fhir:Composition.encounter [
fhir:Reference.reference [ fhir:value "Encounter/FollowupEncounterExample01" ]
];
fhir:Composition.date [ fhir:value "2002-08-23T16:45:50.597-05:00"^^xsd:dateTime];
fhir:Composition.author [
fhir:index 0;
fhir:Reference.reference [ fhir:value "Practitioner/PractitionerExample01" ];
fhir:Reference.display [ fhir:value "赵勇" ]
];
fhir:Composition.title [ fhir:value "高血压患者随访服务记录"];
fhir:Composition.confidentiality [ fhir:value "N"];
fhir:Composition.custodian [
fhir:Reference.reference [ fhir:value "Organization/OrganizationExample01" ];
fhir:Reference.display [ fhir:value "北大人民医院" ]
];
fhir:Composition.section [
fhir:index 0;
fhir:Composition.section.title [ fhir:value "现病史" ];
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:10164-2;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "10164-2" ];
fhir:Coding.display [ fhir:value "History of Present illness" ] ] ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "Condition/EHSymptomsExample01" ] ]
], [
fhir:index 1;
fhir:Composition.section.title [ fhir:value "社会环境史" ];
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:29762-2;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "29762-2" ];
fhir:Coding.display [ fhir:value "Social history" ] ] ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "Observation/DailyACExample01" ] ], [
fhir:index 1;
fhir:Reference.reference [ fhir:value "Observation/DailyCCExample01" ] ], [
fhir:index 2;
fhir:Reference.reference [ fhir:value "Observation/MovementConditionExample01" ] ], [
fhir:index 3;
fhir:Reference.reference [ fhir:value "Observation/SultConditionExample01" ] ]
], [
fhir:index 2;
fhir:Composition.section.title [ fhir:value "生命体征" ];
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:8716-3;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "8716-3" ];
fhir:Coding.display [ fhir:value "Vital signs" ] ] ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "Observation/VitalSignWeightExample01" ] ], [
fhir:index 1;
fhir:Reference.reference [ fhir:value "Observation/VitalSignBMIExample01" ] ], [
fhir:index 2;
fhir:Reference.reference [ fhir:value "Observation/VitalSignBPExample01" ] ], [
fhir:index 3;
fhir:Reference.reference [ fhir:value "Observation/VitalSignHeartRateExample01" ] ]
], [
fhir:index 3;
fhir:Composition.section.title [ fhir:value "辅助检查" ];
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:26436-6;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "26436-6" ];
fhir:Coding.display [ fhir:value "Laboratory data" ] ] ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "Observation/LabResultExample01" ] ]
], [
fhir:index 4;
fhir:Composition.section.title [ fhir:value "当前用药" ];
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:19009-0;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "19009-0" ];
fhir:Coding.display [ fhir:value "Medication current" ] ] ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "MedicationStatement/MedicationUseExample01" ] ]
], [
fhir:index 5;
fhir:Composition.section.title [ fhir:value "过敏和不良反应" ];
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:48765-2;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "48765-2" ];
fhir:Coding.display [ fhir:value "Allergies and adverse reactions" ] ] ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "AllergyIntolerance/MedicationADRExample01" ] ]
], [
fhir:index 6;
fhir:Composition.section.title [ fhir:value "评估与计划" ];
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:51847-2;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "51847-2" ];
fhir:Coding.display [ fhir:value "Evaluation and plan" ] ] ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "Observation/PsychologicalAdjustmentExample01" ] ], [
fhir:index 1;
fhir:Reference.reference [ fhir:value "Observation/MedicationComplianceExample01" ] ], [
fhir:index 2;
fhir:Reference.reference [ fhir:value "Observation/MedicalComplianceExample01" ] ], [
fhir:index 3;
fhir:Reference.reference [ fhir:value "Observation/FollowupAssessmentExample01" ] ]
], [
fhir:index 7;
fhir:Composition.section.title [ fhir:value "治疗计划" ];
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:18776-5;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "18776-5" ];
fhir:Coding.display [ fhir:value "Plan of care" ] ] ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "Goal/GoalWeightExample01" ] ], [
fhir:index 1;
fhir:Reference.reference [ fhir:value "Goal/GoalBMIExample01" ] ], [
fhir:index 2;
fhir:Reference.reference [ fhir:value "Goal/GoalDailyACExample01" ] ], [
fhir:index 3;
fhir:Reference.reference [ fhir:value "Goal/GoalDailyCCExample01" ] ], [
fhir:index 4;
fhir:Reference.reference [ fhir:value "Goal/GoalMovementExample01" ] ], [
fhir:index 5;
fhir:Reference.reference [ fhir:value "Goal/GoalSultExample01" ] ]
], [
fhir:index 8;
fhir:Composition.section.title [ fhir:value "转诊建议" ];
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:42349-1;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "42349-1" ];
fhir:Coding.display [ fhir:value "Reason for referral" ] ] ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "ServiceRequest/ReferralRequestExample01" ] ]
], [
fhir:index 9;
fhir:Composition.section.title [ fhir:value "随访计划" ];
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:21979-0;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "21979-0" ];
fhir:Coding.display [ fhir:value "Planned/next follow-up" ] ] ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "Encounter/NextFollowupEncounterExample01" ] ]
].
# - ontology header ------------------------------------------------------------
a owl:Ontology;
owl:imports fhir:fhir.ttl.