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。

• Narrative Content
• XML
• JSON

: HSDB0401CompositionExample01 - XML Representation

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<Composition xmlns="http://hl7.org/fhir">
  <id value="HSDB0401CompositionExample01"/>
  <meta>
    <profile
             value="http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-document-hsdb04-01"/>
  </meta>
  <text>
    <status value="generated"/>
    <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 --&gt; 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>
  </text>
  <identifier>
    <system value="urn:oid:1.2.10093.1.23.24.3454354"/>
    <value value="N123455"/>
  </identifier>
  <status value="final"/>
  <type>
    <coding>
      <system value="http://hl7.org.cn/fhir/sd/ehr/CodeSystem/ehr-document-type"/>
      <code value="HSDB04.01"/>
      <display value="高血压患者随访服务"/>
    </coding>
  </type>
  <category>
    <coding>
      <system value="http://hl7.org.cn/fhir/sd/ehr/CodeSystem/document-category"/>
      <code value="EHR"/>
      <display value="电子健康档案共享文档"/>
    </coding>
  </category>
  <subject>
    <reference value="Patient/PatientExample01"/>
    <display value="张三"/>
  </subject>
  <encounter>
    <reference value="Encounter/FollowupEncounterExample01"/>
  </encounter>
  <date value="2002-08-23T16:45:50.597-05:00"/>
  <author>
    <reference value="Practitioner/PractitionerExample01"/>
    <display value="赵勇"/>
  </author>
  <title value="高血压患者随访服务记录"/>
  <confidentiality value="N"/>
  <custodian>
    <reference value="Organization/OrganizationExample01"/>
    <display value="北大人民医院"/>
  </custodian>
  <section>
    <title value="现病史"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10164-2"/>
        <display value="History of Present illness"/>
      </coding>
    </code>
    <entry>
      <reference value="Condition/EHSymptomsExample01"/>
    </entry>
  </section>
  <section>
    <title value="社会环境史"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="29762-2"/>
        <display value="Social history"/>
      </coding>
    </code>
    <entry>
      <reference value="Observation/DailyACExample01"/>
    </entry>
    <entry>
      <reference value="Observation/DailyCCExample01"/>
    </entry>
    <entry>
      <reference value="Observation/MovementConditionExample01"/>
    </entry>
    <entry>
      <reference value="Observation/SultConditionExample01"/>
    </entry>
  </section>
  <section>
    <title value="生命体征"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="8716-3"/>
        <display value="Vital signs"/>
      </coding>
    </code>
    <entry>
      <reference value="Observation/VitalSignWeightExample01"/>
    </entry>
    <entry>
      <reference value="Observation/VitalSignBMIExample01"/>
    </entry>
    <entry>
      <reference value="Observation/VitalSignBPExample01"/>
    </entry>
    <entry>
      <reference value="Observation/VitalSignHeartRateExample01"/>
    </entry>
  </section>
  <section>
    <title value="辅助检查"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="26436-6"/>
        <display value="Laboratory data"/>
      </coding>
    </code>
    <entry>
      <reference value="Observation/LabResultExample01"/>
    </entry>
  </section>
  <section>
    <title value="当前用药"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="19009-0"/>
        <display value="Medication current"/>
      </coding>
    </code>
    <entry>
      <reference value="MedicationStatement/MedicationUseExample01"/>
    </entry>
  </section>
  <section>
    <title value="过敏和不良反应"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="48765-2"/>
        <display value="Allergies and adverse reactions"/>
      </coding>
    </code>
    <entry>
      <reference value="AllergyIntolerance/MedicationADRExample01"/>
    </entry>
  </section>
  <section>
    <title value="评估与计划"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="51847-2"/>
        <display value="Evaluation and plan"/>
      </coding>
    </code>
    <entry>
      <reference value="Observation/PsychologicalAdjustmentExample01"/>
    </entry>
    <entry>
      <reference value="Observation/MedicationComplianceExample01"/>
    </entry>
    <entry>
      <reference value="Observation/MedicalComplianceExample01"/>
    </entry>
    <entry>
      <reference value="Observation/FollowupAssessmentExample01"/>
    </entry>
  </section>
  <section>
    <title value="治疗计划"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="18776-5"/>
        <display value="Plan of care"/>
      </coding>
    </code>
    <entry>
      <reference value="Goal/GoalWeightExample01"/>
    </entry>
    <entry>
      <reference value="Goal/GoalBMIExample01"/>
    </entry>
    <entry>
      <reference value="Goal/GoalDailyACExample01"/>
    </entry>
    <entry>
      <reference value="Goal/GoalDailyCCExample01"/>
    </entry>
    <entry>
      <reference value="Goal/GoalMovementExample01"/>
    </entry>
    <entry>
      <reference value="Goal/GoalSultExample01"/>
    </entry>
  </section>
  <section>
    <title value="转诊建议"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="42349-1"/>
        <display value="Reason for referral"/>
      </coding>
    </code>
    <entry>
      <reference value="ServiceRequest/ReferralRequestExample01"/>
    </entry>
  </section>
  <section>
    <title value="随访计划"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="21979-0"/>
        <display value="Planned/next follow-up"/>
      </coding>
    </code>
    <entry>
      <reference value="Encounter/NextFollowupEncounterExample01"/>
    </entry>
  </section>
</Composition>