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

: HSDB0405CompositionExample01 - JSON Representation

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{
  "resourceType" : "Composition",
  "id" : "HSDB0405CompositionExample01",
  "meta" : {
    "profile" : [
      "http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-document-hsdb04-05"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>identifier</b>: id: N123457</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 HSDB04.05}\">冠心病患者随访服务</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-FollowupEncounterExample05.html\">Generated Summary: id: N1233456675; 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>: 冠心病患者随访服务记录</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>"
  },
  "identifier" : {
    "system" : "urn:oid:1.2.10093.1.23.24.3454356",
    "value" : "N123457"
  },
  "status" : "final",
  "type" : {
    "coding" : [
      {
        "system" : "http://hl7.org.cn/fhir/sd/ehr/CodeSystem/ehr-document-type",
        "code" : "HSDB04.05",
        "display" : "冠心病患者随访服务"
      }
    ]
  },
  "category" : [
    {
      "coding" : [
        {
          "system" : "http://hl7.org.cn/fhir/sd/ehr/CodeSystem/document-category",
          "code" : "EHR",
          "display" : "电子健康档案共享文档"
        }
      ]
    }
  ],
  "subject" : {
    "reference" : "Patient/PatientExample01",
    "display" : "张三"
  },
  "encounter" : {
    "reference" : "Encounter/FollowupEncounterExample05"
  },
  "date" : "2002-08-23T16:45:50.597-05:00",
  "author" : [
    {
      "reference" : "Practitioner/PractitionerExample01",
      "display" : "赵勇"
    }
  ],
  "title" : "冠心病患者随访服务记录",
  "confidentiality" : "N",
  "custodian" : {
    "reference" : "Organization/OrganizationExample01",
    "display" : "北大人民医院"
  },
  "section" : [
    {
      "title" : "现病史",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "10164-2",
            "display" : "History of Present illness"
          }
        ]
      },
      "entry" : [
        {
          "reference" : "Condition/CHDSymptomsExample01"
        }
      ]
    },
    {
      "title" : "社会环境史",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "29762-2",
            "display" : "Social history"
          }
        ]
      },
      "entry" : [
        {
          "reference" : "Observation/DailyACExample05"
        },
        {
          "reference" : "Observation/DailyCCExample05"
        },
        {
          "reference" : "Observation/MovementConditionExample05"
        }
      ]
    },
    {
      "title" : "生命体征",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "8716-3",
            "display" : "Vital signs"
          }
        ]
      },
      "entry" : [
        {
          "reference" : "Observation/VitalSignHeightExample05"
        },
        {
          "reference" : "Observation/VitalSignWeightExample05"
        },
        {
          "reference" : "Observation/VitalSignBMIExample05"
        },
        {
          "reference" : "Observation/VitalSignBPExample05"
        },
        {
          "reference" : "Observation/VitalSignHeartRateExample05"
        }
      ]
    },
    {
      "title" : "检验结果",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "26436-6",
            "display" : "Laboratory data"
          }
        ]
      },
      "entry" : [
        {
          "reference" : "Observation/LabResultExample05"
        }
      ]
    },
    {
      "title" : "当前用药",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "19009-0",
            "display" : "Medication current"
          }
        ]
      },
      "entry" : [
        {
          "reference" : "MedicationStatement/MedicationUseExample05"
        }
      ]
    },
    {
      "title" : "过敏和不良反应",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "48765-2",
            "display" : "Allergies and adverse reactions"
          }
        ]
      },
      "entry" : [
        {
          "reference" : "AllergyIntolerance/MedicationADRExample05"
        }
      ]
    },
    {
      "title" : "评估与计划",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "51847-2",
            "display" : "Evaluation and plan"
          }
        ]
      },
      "entry" : [
        {
          "reference" : "Observation/PsychologicalAdjustmentExample05"
        },
        {
          "reference" : "Observation/MedicationComplianceExample05"
        },
        {
          "reference" : "Observation/MedicalComplianceExample05"
        },
        {
          "reference" : "Observation/FollowupAssessmentExample05"
        }
      ]
    },
    {
      "title" : "治疗计划",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "18776-5",
            "display" : "Plan of care"
          }
        ]
      },
      "entry" : [
        {
          "reference" : "Goal/GoalWeightExample05"
        },
        {
          "reference" : "Goal/GoalBMIExample05"
        },
        {
          "reference" : "Goal/GoalDailyACExample05"
        },
        {
          "reference" : "Goal/GoalDailyCCExample05"
        },
        {
          "reference" : "Goal/GoalMovementExample05"
        },
        {
          "reference" : "Observation/TreatmentCHDSpecialExample05"
        }
      ]
    },
    {
      "title" : "转诊建议",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "42349-1",
            "display" : "Reason for referral"
          }
        ]
      },
      "entry" : [
        {
          "reference" : "ServiceRequest/ReferralRequestExample05"
        }
      ]
    },
    {
      "title" : "随访计划",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "21979-0",
            "display" : "Planned/next follow-up"
          }
        ]
      },
      "entry" : [
        {
          "reference" : "Encounter/NextFollowupEncounterExample05"
        }
      ]
    }
  ]
}