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。
{
"resourceType" : "Composition",
"id" : "HSDB0406CompositionExample01",
"meta" : {
"profile" : [
"http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-document-hsdb04-06"
]
},
"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 HSDB04.06}\">脑卒中患者随访服务</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-FollowupEncounterExample06.html\">Generated Summary: id: N1233456674; 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>: 脑卒中患者随访服务记录</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" : "HSDB04.06",
"display" : "脑卒中患者随访服务"
}
]
},
"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/FollowupEncounterExample06"
},
"date" : "2002-08-23T16:45:50.597-05:00",
"author" : [
{
"reference" : "Practitioner/PractitionerExample01",
"display" : "赵勇"
}
],
"title" : "脑卒中患者随访服务记录",
"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/CVASymptomsExample01"
}
]
},
{
"title" : "社会环境史",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29762-2",
"display" : "Social history"
}
]
},
"entry" : [
{
"reference" : "Observation/DailyACExample06"
},
{
"reference" : "Observation/DailyCCExample06"
},
{
"reference" : "Observation/MovementConditionExample06"
}
]
},
{
"title" : "生命体征",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8716-3",
"display" : "Vital signs"
}
]
},
"entry" : [
{
"reference" : "Observation/VitalSignHeightExample06"
},
{
"reference" : "Observation/VitalSignWeightExample06"
},
{
"reference" : "Observation/VitalSignBMIExample06"
},
{
"reference" : "Observation/VitalSignBPExample06"
},
{
"reference" : "Observation/VitalSignHeartRateExample06"
},
{
"reference" : "Observation/VitalSignWaistCircumExample06"
}
]
},
{
"title" : "检验结果",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "26436-6",
"display" : "Laboratory data"
}
]
},
"entry" : [
{
"reference" : "Observation/LabResultExample06"
}
]
},
{
"title" : "当前用药",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "19009-0",
"display" : "Medication current"
}
]
},
"entry" : [
{
"reference" : "MedicationStatement/MedicationUseExample06"
}
]
},
{
"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/MedicationADRExample06"
}
]
},
{
"title" : "评估与计划",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "51847-2",
"display" : "Evaluation and plan"
}
]
},
"entry" : [
{
"reference" : "Observation/PsychologicalAdjustmentExample06"
},
{
"reference" : "Observation/MedicationComplianceExample06"
},
{
"reference" : "Observation/MedicalComplianceExample06"
},
{
"reference" : "Observation/FollowupAssessmentExample06"
}
]
},
{
"title" : "治疗计划",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "18776-5",
"display" : "Plan of care"
}
]
},
"entry" : [
{
"reference" : "Goal/GoalWeightExample06"
},
{
"reference" : "Goal/GoalBMIExample06"
},
{
"reference" : "Goal/GoalDailyACExample06"
},
{
"reference" : "Goal/GoalDailyCCExample06"
},
{
"reference" : "Goal/GoalMovementExample06"
}
]
},
{
"title" : "转诊建议",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "42349-1",
"display" : "Reason for referral"
}
]
},
"entry" : [
{
"reference" : "ServiceRequest/ReferralRequestExample06"
}
]
},
{
"title" : "随访计划",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "21979-0",
"display" : "Planned/next follow-up"
}
]
},
"entry" : [
{
"reference" : "Encounter/NextFollowupEncounterExample06"
}
]
}
]
}