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。
| Defining URL: | http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-allergy-history |
| Version: | 0.8.0.2022705 |
| Name: | AllergyHistory |
| Title: | 过敏史结构定义 |
| Status: | Active as of 2022-07-05T13:46:42+08:00 |
| Definition: | 过敏史资源本地化定义。 |
| Publisher: | CHIMA&HL7中国委员会 |
| Source Resource: | XML / JSON / Turtle |
过敏史结构定义的正式唯一标识为:
http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-allergy-history
过敏史结构定义是在FHIR标准的AllergyIntolerance基础上进行更加详细的规则约束，下表展示了过敏史结构定义的结构表示。
这种结构源自 AllergyIntolerance
这种结构源自 AllergyIntolerance
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  AllergyIntolerance | 0..* | AllergyIntolerance | Allergy or Intolerance (generally: Risk of adverse reaction to a substance) | |
  type | 1..1 | code | 类型。固定为过敏 Required Pattern: allergy | |
| category | 0..1 | code | 过敏的分类。可选取值有：食物、药物、环境、生物 | |
| code | 1..1 | CodeableConcept | 过敏源编码 Binding: 过敏源代码表 (required) | |
| patient | 1..1 | Reference(Patient) | 患者 | |
  onset[x] | S | 0..1 | dateTime | 过敏发生时间 |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| AllergyIntolerance | I | 0..* | AllergyIntolerance | Allergy or Intolerance (generally: Risk of adverse reaction to a substance) |
| id | Σ | 0..1 | string | Logical id of this artifact |
 meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
 extension | 0..* | Extension | Additional content defined by implementations | |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 0..* | Identifier | External ids for this item |
| clinicalStatus | ?!ΣI | 0..1 | CodeableConcept | active | inactive | resolved Binding: AllergyIntoleranceClinicalStatusCodes (required): The clinical status of the allergy or intolerance. |
| verificationStatus | ?!ΣI | 0..1 | CodeableConcept | unconfirmed | confirmed | refuted | entered-in-error Binding: AllergyIntoleranceVerificationStatusCodes (required): Assertion about certainty associated with a propensity, or potential risk, of a reaction to the identified substance. |
| type | Σ | 1..1 | code | 类型。固定为过敏 Binding: AllergyIntoleranceType (required): Identification of the underlying physiological mechanism for a Reaction Risk. Required Pattern: allergy |
| category | Σ | 0..1 | code | 过敏的分类。可选取值有：食物、药物、环境、生物 Binding: AllergyIntoleranceCategory (required): Category of an identified substance associated with allergies or intolerances. |
| criticality | Σ | 0..1 | code | low | high | unable-to-assess Binding: AllergyIntoleranceCriticality (required): Estimate of the potential clinical harm, or seriousness, of a reaction to an identified substance. |
| code | Σ | 1..1 | CodeableConcept | 过敏源编码 Binding: 过敏源代码表 (required) |
 patient | Σ | 1..1 | Reference(Patient) | 患者 |
| encounter | 0..1 | Reference(Encounter) | Encounter when the allergy or intolerance was asserted | |
| onset[x] | S | 0..1 | dateTime | 过敏发生时间 |
| recordedDate | 0..1 | dateTime | Date first version of the resource instance was recorded | |
| recorder | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the sensitivity | |
| asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Source of the information about the allergy |
| lastOccurrence | 0..1 | dateTime | Date(/time) of last known occurrence of a reaction | |
| note | 0..* | Annotation | Additional text not captured in other fields | |
 reaction | 0..* | BackboneElement | Adverse Reaction Events linked to exposure to substance | |
 id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| substance | 0..1 | CodeableConcept | Specific substance or pharmaceutical product considered to be responsible for event Binding: SubstanceCode (example): Codes defining the type of the substance (including pharmaceutical products). | |
| manifestation | 1..* | CodeableConcept | Clinical symptoms/signs associated with the Event Binding: SNOMEDCTClinicalFindings (example): Clinical symptoms and/or signs that are observed or associated with an Adverse Reaction Event. | |
| description | 0..1 | string | Description of the event as a whole | |
| onset | 0..1 | dateTime | Date(/time) when manifestations showed | |
| severity | 0..1 | code | mild | moderate | severe (of event as a whole) Binding: AllergyIntoleranceSeverity (required): Clinical assessment of the severity of a reaction event as a whole, potentially considering multiple different manifestations. | |
| exposureRoute | 0..1 | CodeableConcept | How the subject was exposed to the substance Binding: SNOMEDCTRouteCodes (example): A coded concept describing the route or physiological path of administration of a therapeutic agent into or onto the body of a subject. | |
| note | 0..* | Annotation | Text about event not captured in other fields | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| AllergyIntolerance | I | 0..* | AllergyIntolerance | Allergy or Intolerance (generally: Risk of adverse reaction to a substance) |
| onset[x] | 0..1 | dateTime | 过敏发生时间 | |
| Documentation for this format | ||||
这种结构源自 AllergyIntolerance
差异视图
这种结构源自 AllergyIntolerance
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| AllergyIntolerance | 0..* | AllergyIntolerance | Allergy or Intolerance (generally: Risk of adverse reaction to a substance) | |
| type | 1..1 | code | 类型。固定为过敏 Required Pattern: allergy | |
| category | 0..1 | code | 过敏的分类。可选取值有：食物、药物、环境、生物 | |
| code | 1..1 | CodeableConcept | 过敏源编码 Binding: 过敏源代码表 (required) | |
| patient | 1..1 | Reference(Patient) | 患者 | |
| onset[x] | S | 0..1 | dateTime | 过敏发生时间 |
| Documentation for this format | ||||
快照视图
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| AllergyIntolerance | I | 0..* | AllergyIntolerance | Allergy or Intolerance (generally: Risk of adverse reaction to a substance) |
| id | Σ | 0..1 | string | Logical id of this artifact |
| meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 0..* | Identifier | External ids for this item |
| clinicalStatus | ?!ΣI | 0..1 | CodeableConcept | active | inactive | resolved Binding: AllergyIntoleranceClinicalStatusCodes (required): The clinical status of the allergy or intolerance. |
| verificationStatus | ?!ΣI | 0..1 | CodeableConcept | unconfirmed | confirmed | refuted | entered-in-error Binding: AllergyIntoleranceVerificationStatusCodes (required): Assertion about certainty associated with a propensity, or potential risk, of a reaction to the identified substance. |
| type | Σ | 1..1 | code | 类型。固定为过敏 Binding: AllergyIntoleranceType (required): Identification of the underlying physiological mechanism for a Reaction Risk. Required Pattern: allergy |
| category | Σ | 0..1 | code | 过敏的分类。可选取值有：食物、药物、环境、生物 Binding: AllergyIntoleranceCategory (required): Category of an identified substance associated with allergies or intolerances. |
| criticality | Σ | 0..1 | code | low | high | unable-to-assess Binding: AllergyIntoleranceCriticality (required): Estimate of the potential clinical harm, or seriousness, of a reaction to an identified substance. |
| code | Σ | 1..1 | CodeableConcept | 过敏源编码 Binding: 过敏源代码表 (required) |
| patient | Σ | 1..1 | Reference(Patient) | 患者 |
| encounter | 0..1 | Reference(Encounter) | Encounter when the allergy or intolerance was asserted | |
| onset[x] | S | 0..1 | dateTime | 过敏发生时间 |
| recordedDate | 0..1 | dateTime | Date first version of the resource instance was recorded | |
| recorder | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the sensitivity | |
| asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Source of the information about the allergy |
| lastOccurrence | 0..1 | dateTime | Date(/time) of last known occurrence of a reaction | |
| note | 0..* | Annotation | Additional text not captured in other fields | |
| reaction | 0..* | BackboneElement | Adverse Reaction Events linked to exposure to substance | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| substance | 0..1 | CodeableConcept | Specific substance or pharmaceutical product considered to be responsible for event Binding: SubstanceCode (example): Codes defining the type of the substance (including pharmaceutical products). | |
| manifestation | 1..* | CodeableConcept | Clinical symptoms/signs associated with the Event Binding: SNOMEDCTClinicalFindings (example): Clinical symptoms and/or signs that are observed or associated with an Adverse Reaction Event. | |
| description | 0..1 | string | Description of the event as a whole | |
| onset | 0..1 | dateTime | Date(/time) when manifestations showed | |
| severity | 0..1 | code | mild | moderate | severe (of event as a whole) Binding: AllergyIntoleranceSeverity (required): Clinical assessment of the severity of a reaction event as a whole, potentially considering multiple different manifestations. | |
| exposureRoute | 0..1 | CodeableConcept | How the subject was exposed to the substance Binding: SNOMEDCTRouteCodes (example): A coded concept describing the route or physiological path of administration of a therapeutic agent into or onto the body of a subject. | |
| note | 0..* | Annotation | Text about event not captured in other fields | |
| Documentation for this format | ||||
本定义的其它表示法: Schematron
| Path | Conformance | ValueSet / Code |
| AllergyIntolerance.language | preferred | CommonLanguages Max Binding: AllLanguages |
| AllergyIntolerance.clinicalStatus | required | AllergyIntoleranceClinicalStatusCodes |
| AllergyIntolerance.verificationStatus | required | AllergyIntoleranceVerificationStatusCodes |
| AllergyIntolerance.type | required | Pattern: allergy |
| AllergyIntolerance.category | required | AllergyIntoleranceCategory |
| AllergyIntolerance.criticality | required | AllergyIntoleranceCriticality |
| AllergyIntolerance.code | required | CV05_01_038 |
| AllergyIntolerance.reaction.substance | example | SubstanceCode |
| AllergyIntolerance.reaction.manifestation | example | SNOMEDCTClinicalFindings |
| AllergyIntolerance.reaction.severity | required | AllergyIntoleranceSeverity |
| AllergyIntolerance.reaction.exposureRoute | example | SNOMEDCTRouteCodes |
| Id | Path | Details | Requirements |
| ait-1 | AllergyIntolerance | AllergyIntolerance.clinicalStatus SHALL be present if verificationStatus is not entered-in-error. : verificationStatus.coding.where(system = 'http://terminology.hl7.org/CodeSystem/allergyintolerance-verification' and code = 'entered-in-error').exists() or clinicalStatus.exists() | |
| ait-2 | AllergyIntolerance | AllergyIntolerance.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system = 'http://terminology.hl7.org/CodeSystem/allergyintolerance-verification' and code = 'entered-in-error').empty() or clinicalStatus.empty() | |
| dom-2 | AllergyIntolerance | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | AllergyIntolerance | If 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().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | AllergyIntolerance | If 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-5 | AllergyIntolerance | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | AllergyIntolerance | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | AllergyIntolerance.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | AllergyIntolerance.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | AllergyIntolerance.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | AllergyIntolerance.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | AllergyIntolerance.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.clinicalStatus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.verificationStatus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.category | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.criticality | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.patient | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.encounter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.onset[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.recordedDate | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.recorder | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.asserter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.lastOccurrence | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.note | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.reaction | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.reaction.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | AllergyIntolerance.reaction.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | AllergyIntolerance.reaction.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | AllergyIntolerance.reaction.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | AllergyIntolerance.reaction.substance | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.reaction.manifestation | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.reaction.description | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.reaction.onset | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.reaction.severity | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.reaction.exposureRoute | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | AllergyIntolerance.reaction.note | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |