基于FHIR标准的健康档案共享文档实施指南-疾病史结构定义

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。

Resource Profile: 疾病史结构定义

Defining URL:

http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-diseases-history

Version:

0.8.0.2022705

Name:

DiseasesHistory

Title:

疾病史结构定义

Status:

Active as of 2022-07-05T13:46:42+08:00

Definition:

疾病史结构定义。

Publisher:

CHIMA&HL7中国委员会

Source Resource:

XML / JSON / Turtle

疾病史结构定义的正式唯一标识为:

http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-diseases-history

定义内容的视图

疾病史结构定义是在FHIR标准的Condition基础上进行更加详细的规则约束，下表展示了疾病史结构定义的结构表示。

关于定义、差异、快照以及如何解读这些表示法。

文本摘要
差异表
快照表
快照表(Must Support)
All

这种结构源自 Condition

Summary

Mandatory: 2 elements
Must-Support: 1 element

Structures

This structure refers to these other structures:

http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-core-patient

这种结构源自 Condition

Name	Flags	Card.	Type	Description & Constraints
Condition		0..*	Condition	Detailed information about conditions, problems or diagnoses
category		1..1	CodeableConcept	problem-list-item \| encounter-diagnosis Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
code		1..1	code	Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
display		1..1	string	Representation defined by the system Fixed Value: 疾病诊断
code		1..1	CodeableConcept	记录居民的既往常见疾病 Binding: 既往常见疾病种类代码表 (required)
subject		1..1	Reference(患者信息结构定义)	指向患者的引用
onset[x]	S	0..1	dateTime, Age, Period, Range, string	疾病的确诊时间。可以提供精确时间，也可以提供时间区间，或者发生时的年龄
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Condition	I	0..*	Condition	Detailed information about conditions, problems or diagnoses
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 condition
clinicalStatus	?!ΣI	0..1	CodeableConcept	active \| recurrence \| relapse \| inactive \| remission \| resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus	?!ΣI	0..1	CodeableConcept	unconfirmed \| provisional \| differential \| confirmed \| refuted \| entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
category		1..1	CodeableConcept	problem-list-item \| encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
display		1..1	string	Representation defined by the system Fixed Value: 疾病诊断
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
severity		0..1	CodeableConcept	Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
code	Σ	1..1	CodeableConcept	记录居民的既往常见疾病 Binding: 既往常见疾病种类代码表 (required)
bodySite	Σ	0..*	CodeableConcept	Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
subject	Σ	1..1	Reference(患者信息结构定义)	指向患者的引用
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
onset[x]	SΣ	0..1		疾病的确诊时间。可以提供精确时间，也可以提供时间区间，或者发生时的年龄
onsetDateTime			dateTime
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
abatement[x]	I	0..1		When in resolution/remission
abatementDateTime			dateTime
abatementAge			Age
abatementPeriod			Period
abatementRange			Range
abatementString			string
recordedDate	Σ	0..1	dateTime	Date record was first recorded
recorder	Σ	0..1	Reference(Practitioner \| PractitionerRole \| Patient \| RelatedPerson)	Who recorded the condition
asserter	Σ	0..1	Reference(Practitioner \| PractitionerRole \| Patient \| RelatedPerson)	Person who asserts this condition
stage	I	0..*	BackboneElement	Stage/grade, usually assessed formally con-1: Stage SHALL have summary or assessment
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
summary	I	0..1	CodeableConcept	Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
assessment	I	0..*	Reference(ClinicalImpression \| DiagnosticReport \| Observation)	Formal record of assessment
type		0..1	CodeableConcept	Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).
evidence	I	0..*	BackboneElement	Supporting evidence con-2: evidence SHALL have code or details
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
code	ΣI	0..*	CodeableConcept	Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
detail	ΣI	0..*	Reference(Resource)	Supporting information found elsewhere
note		0..*	Annotation	Additional information about the Condition
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Condition	I	0..*	Condition	Detailed information about conditions, problems or diagnoses
onset[x]	Σ	0..1		疾病的确诊时间。可以提供精确时间，也可以提供时间区间，或者发生时的年龄
onsetDateTime			dateTime
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
Documentation for this format

这种结构源自 Condition

Summary

Mandatory: 2 elements
Must-Support: 1 element

Structures

This structure refers to these other structures:

http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-core-patient

差异视图

这种结构源自 Condition

Name	Flags	Card.	Type	Description & Constraints
Condition		0..*	Condition	Detailed information about conditions, problems or diagnoses
category		1..1	CodeableConcept	problem-list-item \| encounter-diagnosis Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
code		1..1	code	Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
display		1..1	string	Representation defined by the system Fixed Value: 疾病诊断
code		1..1	CodeableConcept	记录居民的既往常见疾病 Binding: 既往常见疾病种类代码表 (required)
subject		1..1	Reference(患者信息结构定义)	指向患者的引用
onset[x]	S	0..1	dateTime, Age, Period, Range, string	疾病的确诊时间。可以提供精确时间，也可以提供时间区间，或者发生时的年龄
Documentation for this format

快照视图

Name	Flags	Card.	Type	Description & Constraints
Condition	I	0..*	Condition	Detailed information about conditions, problems or diagnoses
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 condition
clinicalStatus	?!ΣI	0..1	CodeableConcept	active \| recurrence \| relapse \| inactive \| remission \| resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus	?!ΣI	0..1	CodeableConcept	unconfirmed \| provisional \| differential \| confirmed \| refuted \| entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
category		1..1	CodeableConcept	problem-list-item \| encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
display		1..1	string	Representation defined by the system Fixed Value: 疾病诊断
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
severity		0..1	CodeableConcept	Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
code	Σ	1..1	CodeableConcept	记录居民的既往常见疾病 Binding: 既往常见疾病种类代码表 (required)
bodySite	Σ	0..*	CodeableConcept	Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
subject	Σ	1..1	Reference(患者信息结构定义)	指向患者的引用
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
onset[x]	SΣ	0..1		疾病的确诊时间。可以提供精确时间，也可以提供时间区间，或者发生时的年龄
onsetDateTime			dateTime
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
abatement[x]	I	0..1		When in resolution/remission
abatementDateTime			dateTime
abatementAge			Age
abatementPeriod			Period
abatementRange			Range
abatementString			string
recordedDate	Σ	0..1	dateTime	Date record was first recorded
recorder	Σ	0..1	Reference(Practitioner \| PractitionerRole \| Patient \| RelatedPerson)	Who recorded the condition
asserter	Σ	0..1	Reference(Practitioner \| PractitionerRole \| Patient \| RelatedPerson)	Person who asserts this condition
stage	I	0..*	BackboneElement	Stage/grade, usually assessed formally con-1: Stage SHALL have summary or assessment
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
summary	I	0..1	CodeableConcept	Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
assessment	I	0..*	Reference(ClinicalImpression \| DiagnosticReport \| Observation)	Formal record of assessment
type		0..1	CodeableConcept	Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).
evidence	I	0..*	BackboneElement	Supporting evidence con-2: evidence SHALL have code or details
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
code	ΣI	0..*	CodeableConcept	Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
detail	ΣI	0..*	Reference(Resource)	Supporting information found elsewhere
note		0..*	Annotation	Additional information about the Condition
Documentation for this format

本定义的其它表示法: Schematron

Terminology Bindings

Path	Conformance	ValueSet / Code
Condition.language	preferred	CommonLanguages Max Binding: AllLanguages
Condition.clinicalStatus	required	ConditionClinicalStatusCodes
Condition.verificationStatus	required	ConditionVerificationStatus
Condition.category	extensible	Pattern: encounter-diagnosis("疾病诊断")
Condition.severity	preferred	Condition/DiagnosisSeverity
Condition.code	required	CV02_10_005
Condition.bodySite	example	SNOMEDCTBodyStructures
Condition.stage.summary	example	ConditionStage
Condition.stage.type	example	ConditionStageType
Condition.evidence.code	example	ManifestationAndSymptomCodes

Constraints

Id	Path	Details	Requirements
con-3	Condition	Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4	Condition	If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5	Condition	Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2	Condition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	Condition	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	Condition	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	Condition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	Condition	A resource should have narrative for robust management : text.`div`.exists()
ele-1	Condition.meta	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.implicitRules	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.language	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.text	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Condition.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Condition.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Condition.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Condition.identifier	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.clinicalStatus	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.verificationStatus	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.category	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.severity	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.code	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.bodySite	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.subject	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.encounter	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.onset[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.abatement[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.recordedDate	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.recorder	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.asserter	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
con-1	Condition.stage	Stage SHALL have summary or assessment : summary.exists() or assessment.exists()
ele-1	Condition.stage	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.stage.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Condition.stage.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Condition.stage.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Condition.stage.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Condition.stage.summary	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.stage.assessment	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.stage.type	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
con-2	Condition.evidence	evidence SHALL have code or details : code.exists() or detail.exists()
ele-1	Condition.evidence	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.evidence.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Condition.evidence.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Condition.evidence.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Condition.evidence.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Condition.evidence.code	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.evidence.detail	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Condition.note	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())