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-document-hsdb04-02 |
Version: | 0.8.0.2022705 |
Name: | DocumentHSDB0402 |
Title: | II型糖尿病患者随访服务共享文档本地化定义 |
Status: | Active as of 2022-07-05T13:46:42+08:00 |
Definition: | II型糖尿病患者随访服务共享文档本地化定义。 |
Publisher: | CHIMA&HL7中国委员会 |
Source Resource: | XML / JSON / Turtle |
II型糖尿病患者随访服务共享文档本地化定义的正式唯一标识为:
http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-document-hsdb04-02
II型糖尿病患者随访服务共享文档本地化定义是在FHIR标准的RealmHeader基础上进行更加详细的规则约束,下表展示了II型糖尿病患者随访服务共享文档本地化定义的结构表示。
这种结构源自 RealmHeader
Summary
Mandatory: 11 elements (1 nested mandatory element)
Must-Support: 3 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
这种结构源自 RealmHeader
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | RealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |
type | 1..1 | CodeableConcept | 文档类型,由具体的文档定义指定其类型 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://hl7.org.cn/fhir/sd/ehr/CodeSystem/ehr-document-type | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: HSDB04.02 | |
display | 1..1 | string | Representation defined by the system Fixed Value: II型糖尿病患者随访服务 | |
category | 1..1 | CodeableConcept | 文档的分类:EMR|EHR|PHR 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://hl7.org.cn/fhir/sd/ehr/CodeSystem/document-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: EHR | |
display | 1..1 | string | Representation defined by the system Fixed Value: 电子健康档案共享文档 | |
encounter | 0..1 | Reference(随访服务结构定义) | Context of the Composition | |
title | 1..1 | string | 文档的标题 Required Pattern: II型糖尿病患者随访服务记录 | |
section | 7..* | (Slice Definition) | 文档的具体章节 Slice: Unordered, Open by value:code | |
section:PresentHistory | 1..1 | BackboneElement | Composition is broken into sections | |
title | 1..1 | string | 章节标题 Required Pattern: 现病史 | |
code | 1..1 | CodeableConcept | 章节的编码表示 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: History of Present illness | |
text | 0..1 | Narrative | 以文本形式描述现病史,如果当前未得病,可以写无现病史 | |
entry | 0..* | Reference(糖尿病症状结构定义) | 指向本地化定义的糖尿病症状资源 | |
section:SocialHistory | 1..1 | BackboneElement | Composition is broken into sections | |
title | 1..1 | string | 章节标题 Required Pattern: 社会环境史 | |
code | 1..1 | CodeableConcept | 章节的编码表示 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Social history | |
entry | 1..* | Reference(日饮酒量结构定义 | 日吸烟量结构定义 | 日主食量结构定义 | 运动情况结构定义) | 指向本地化定义的生活方式资源,包括日吸烟量、日饮酒量、日主食量和运动情况 | |
section:VitalSigns | 1..1 | BackboneElement | 记录随访时的患者的多种生命体征信息。 | |
title | 1..1 | string | 章节标题 Required Pattern: 生命体征 | |
code | 1..1 | CodeableConcept | 章节的编码表示 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Vital signs | |
entry | 1..* | Reference(体重结构定义 | 体质指数结构定义 | 血压结构定义) | 指向本地化定义的生命体征资源 | |
section:LabResult | S | 0..1 | BackboneElement | 记录随访时为患者做的辅助检查。 |
title | 1..1 | string | 章节标题 Required Pattern: 辅助检查 | |
code | 1..1 | CodeableConcept | 章节的编码表示 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 26436-6 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Laboratory data | |
entry | 0..* | Reference(检验结果结构定义) | 指向本地化定义的辅助检查资源 | |
section:CurrentMedUse | 1..1 | BackboneElement | 记录随访周期内患者的用药情况。 | |
title | 1..1 | string | 章节标题 Required Pattern: 当前用药 | |
code | 1..1 | CodeableConcept | 章节的编码表示 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 19009-0 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Medication current | |
entry | 0..* | Reference(用药声明结构定义) | 指向本地化定义的当前用药资源 | |
section:ADR | S | 0..1 | BackboneElement | 记录随访周期内患者的用药不良反应。 |
title | 1..1 | string | 章节标题 Required Pattern: 过敏和不良反应 | |
code | 1..1 | CodeableConcept | 章节的编码表示 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Allergies and adverse reactions | |
entry | 0..* | Reference(药物不良反应结构定义) | 指向本地化定义的药物不良反应资源 | |
section:Assessment | 1..1 | BackboneElement | 记录随访时为患者做的评估和目标规划。 | |
title | 1..1 | string | 章节标题 Required Pattern: 评估与计划 | |
code | 1..1 | CodeableConcept | 章节的编码表示 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Evaluation and plan | |
entry | 0..1 | Reference(心理调整评价结构定义 | 服药依从性结构定义 | 遵医行为评估结构定义 | 随访评估结构定义) | 指向本地化定义的生活方式评估资源 | |
section:TreatmentPlan | 1..1 | BackboneElement | 记录随访时为患者做的目标和治疗计划。 | |
title | 1..1 | string | 章节标题 Required Pattern: 治疗计划 | |
code | 1..1 | CodeableConcept | 章节的编码表示 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Plan of care | |
entry | 1..* | Reference(目标体重结构定义 | 目标体质指数结构定义 | 目标日饮酒量结构定义 | 日吸烟量目标结构定义 | 目标运动情况结构定义 | 日主食量目标结构定义) | 指向本地化定义的生活方式目标资源 | |
section:Referral | S | 0..1 | BackboneElement | 记录随访时为患者提出的转诊申请。 |
title | 1..1 | string | 章节标题 Required Pattern: 转诊建议 | |
code | 1..1 | CodeableConcept | 章节的编码表示 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42349-1 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Reason for referral | |
entry | 1..1 | Reference(转诊申请结构定义) | 指向本地化定义的转诊申请资源 | |
section:Plan | 1..1 | BackboneElement | 记录下一次的随访计划。 | |
title | 1..1 | string | 章节标题 Required Pattern: 随访计划 | |
code | 1..1 | CodeableConcept | 章节的编码表示 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 21979-0 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Planned/next follow-up | |
entry | 1..1 | Reference(随访服务结构定义) | 指向本地化定义的随访活动资源 | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | RealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |
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 | Extension Slice: Unordered, Open by value:url | |
composition-clinicaldocument-versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
ext-composition-dataEnterer | 0..1 | Reference(Practitioner | PractitionerRole) | 文档的数据录入者 URL: http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/ext-composition-dataEnterer | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | Σ | 1..1 | Identifier | 文档的业务标识符 |
status | ?!Σ | 1..1 | code | 文档的状态 Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
type | Σ | 1..1 | CodeableConcept | 文档类型,由具体的文档定义指定其类型 Binding: 健康档案共享文档类型代码表 (required) 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://hl7.org.cn/fhir/sd/ehr/CodeSystem/ehr-document-type | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: HSDB04.02 | |
display | 1..1 | string | Representation defined by the system Fixed Value: II型糖尿病患者随访服务 | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
category | Σ | 1..1 | CodeableConcept | 文档的分类:EMR|EHR|PHR Binding: 共享文档类别代码表 (required) 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://hl7.org.cn/fhir/sd/ehr/CodeSystem/document-category | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: EHR | |
display | 1..1 | string | Representation defined by the system Fixed Value: 电子健康档案共享文档 | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
subject | Σ | 1..1 | Reference(患者信息结构定义) | 指向诊疗活动中的患者 |
encounter | Σ | 0..1 | Reference(随访服务结构定义) | Context of the Composition |
date | Σ | 1..1 | dateTime | 文档的生成时间 |
author | Σ | 1..1 | Reference(卫生服务人员信息结构定义) | 文档的作者 |
title | Σ | 1..1 | string | 文档的标题 Required Pattern: II型糖尿病患者随访服务记录 |
confidentiality | Σ | 1..1 | code | 文档的保密级别 Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. |
attester | 0..* | BackboneElement | 文档的责任人 | |
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 |
mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |
time | 0..1 | dateTime | When the composition was attested | |
party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |
custodian | Σ | 1..1 | Reference(医疗机构结构定义) | 文档所属管理机构 |
relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |
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 | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |
target[x] | 1..1 | Target of the relationship | ||
targetIdentifier | Identifier | |||
targetReference | Reference(Composition) | |||
event | Σ | 0..* | BackboneElement | 文档记录的事件列表 |
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 | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. |
period | Σ | 0..1 | Period | The period covered by the documentation |
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented |
section | I | 7..* | (Slice Definition) | 文档的具体章节 Slice: Unordered, Open by value:code |
section:All Slices | Content/Rules for all slices | |||
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 |
title | 1..1 | string | 章节标题 | |
code | 1..1 | CodeableConcept | 章节的编码表示 Binding: 共享文档章节代码表 (required) | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | I | 0..1 | Narrative | 文本描述 |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
entry | I | 0..* | Reference(Resource) | 章节所包含的条目,指向一个资源 |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section | I | 0..* | See section (Composition) | Nested Section |
section:PresentHistory | I | 1..1 | BackboneElement | Composition is broken into sections |
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 |
title | 1..1 | string | 章节标题 Required Pattern: 现病史 | |
code | 1..1 | CodeableConcept | 章节的编码表示 Binding: 共享文档章节代码表 (required) 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://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: History of Present illness | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | I | 0..1 | Narrative | 以文本形式描述现病史,如果当前未得病,可以写无现病史 |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
entry | I | 0..* | Reference(糖尿病症状结构定义) | 指向本地化定义的糖尿病症状资源 |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section | I | 0..* | See section (Composition) | Nested Section |
section:SocialHistory | I | 1..1 | BackboneElement | Composition is broken into sections |
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 |
title | 1..1 | string | 章节标题 Required Pattern: 社会环境史 | |
code | 1..1 | CodeableConcept | 章节的编码表示 Binding: 共享文档章节代码表 (required) 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://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Social history | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | I | 0..1 | Narrative | 文本描述 |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
entry | I | 1..* | Reference(日饮酒量结构定义 | 日吸烟量结构定义 | 日主食量结构定义 | 运动情况结构定义) | 指向本地化定义的生活方式资源,包括日吸烟量、日饮酒量、日主食量和运动情况 |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section | I | 0..* | See section (Composition) | Nested Section |
section:VitalSigns | I | 1..1 | BackboneElement | 记录随访时的患者的多种生命体征信息。 |
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 |
title | 1..1 | string | 章节标题 Required Pattern: 生命体征 | |
code | 1..1 | CodeableConcept | 章节的编码表示 Binding: 共享文档章节代码表 (required) 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://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Vital signs | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | I | 0..1 | Narrative | 文本描述 |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
entry | I | 1..* | Reference(体重结构定义 | 体质指数结构定义 | 血压结构定义) | 指向本地化定义的生命体征资源 |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section | I | 0..* | See section (Composition) | Nested Section |
section:LabResult | SI | 0..1 | BackboneElement | 记录随访时为患者做的辅助检查。 |
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 |
title | 1..1 | string | 章节标题 Required Pattern: 辅助检查 | |
code | 1..1 | CodeableConcept | 章节的编码表示 Binding: 共享文档章节代码表 (required) 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://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 26436-6 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Laboratory data | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | I | 0..1 | Narrative | 文本描述 |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
entry | I | 0..* | Reference(检验结果结构定义) | 指向本地化定义的辅助检查资源 |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section | I | 0..* | See section (Composition) | Nested Section |
section:CurrentMedUse | I | 1..1 | BackboneElement | 记录随访周期内患者的用药情况。 |
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 |
title | 1..1 | string | 章节标题 Required Pattern: 当前用药 | |
code | 1..1 | CodeableConcept | 章节的编码表示 Binding: 共享文档章节代码表 (required) 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://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 19009-0 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Medication current | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | I | 0..1 | Narrative | 文本描述 |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
entry | I | 0..* | Reference(用药声明结构定义) | 指向本地化定义的当前用药资源 |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section | I | 0..* | See section (Composition) | Nested Section |
section:ADR | SI | 0..1 | BackboneElement | 记录随访周期内患者的用药不良反应。 |
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 |
title | 1..1 | string | 章节标题 Required Pattern: 过敏和不良反应 | |
code | 1..1 | CodeableConcept | 章节的编码表示 Binding: 共享文档章节代码表 (required) 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://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Allergies and adverse reactions | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | I | 0..1 | Narrative | 文本描述 |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
entry | I | 0..* | Reference(药物不良反应结构定义) | 指向本地化定义的药物不良反应资源 |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section | I | 0..* | See section (Composition) | Nested Section |
section:Assessment | I | 1..1 | BackboneElement | 记录随访时为患者做的评估和目标规划。 |
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 |
title | 1..1 | string | 章节标题 Required Pattern: 评估与计划 | |
code | 1..1 | CodeableConcept | 章节的编码表示 Binding: 共享文档章节代码表 (required) 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://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Evaluation and plan | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | I | 0..1 | Narrative | 文本描述 |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
entry | I | 0..1 | Reference(心理调整评价结构定义 | 服药依从性结构定义 | 遵医行为评估结构定义 | 随访评估结构定义) | 指向本地化定义的生活方式评估资源 |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section | I | 0..* | See section (Composition) | Nested Section |
section:TreatmentPlan | I | 1..1 | BackboneElement | 记录随访时为患者做的目标和治疗计划。 |
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 |
title | 1..1 | string | 章节标题 Required Pattern: 治疗计划 | |
code | 1..1 | CodeableConcept | 章节的编码表示 Binding: 共享文档章节代码表 (required) 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://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Plan of care | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | I | 0..1 | Narrative | 文本描述 |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
entry | I | 1..* | Reference(目标体重结构定义 | 目标体质指数结构定义 | 目标日饮酒量结构定义 | 日吸烟量目标结构定义 | 目标运动情况结构定义 | 日主食量目标结构定义) | 指向本地化定义的生活方式目标资源 |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section | I | 0..* | See section (Composition) | Nested Section |
section:Referral | SI | 0..1 | BackboneElement | 记录随访时为患者提出的转诊申请。 |
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 |
title | 1..1 | string | 章节标题 Required Pattern: 转诊建议 | |
code | 1..1 | CodeableConcept | 章节的编码表示 Binding: 共享文档章节代码表 (required) 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://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42349-1 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Reason for referral | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | I | 0..1 | Narrative | 文本描述 |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
entry | I | 1..1 | Reference(转诊申请结构定义) | 指向本地化定义的转诊申请资源 |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section | I | 0..* | See section (Composition) | Nested Section |
section:Plan | I | 1..1 | BackboneElement | 记录下一次的随访计划。 |
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 |
title | 1..1 | string | 章节标题 Required Pattern: 随访计划 | |
code | 1..1 | CodeableConcept | 章节的编码表示 Binding: 共享文档章节代码表 (required) 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://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 21979-0 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Planned/next follow-up | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | I | 0..1 | Narrative | 文本描述 |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
entry | I | 1..1 | Reference(随访服务结构定义) | 指向本地化定义的随访活动资源 |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section | I | 0..* | See section (Composition) | Nested Section |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | RealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |
section:LabResult | I | 0..1 | BackboneElement | 记录随访时为患者做的辅助检查。 |
section:ADR | I | 0..1 | BackboneElement | 记录随访周期内患者的用药不良反应。 |
section:Referral | I | 0..1 | BackboneElement | 记录随访时为患者提出的转诊申请。 |
Documentation for this format |
这种结构源自 RealmHeader
Summary
Mandatory: 11 elements (1 nested mandatory element)
Must-Support: 3 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
差异视图
这种结构源自 RealmHeader
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | RealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |
type | 1..1 | CodeableConcept | 文档类型,由具体的文档定义指定其类型 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://hl7.org.cn/fhir/sd/ehr/CodeSystem/ehr-document-type | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: HSDB04.02 | |
display | 1..1 | string | Representation defined by the system Fixed Value: II型糖尿病患者随访服务 | |
category | 1..1 | CodeableConcept | 文档的分类:EMR|EHR|PHR 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://hl7.org.cn/fhir/sd/ehr/CodeSystem/document-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: EHR | |
display | 1..1 | string | Representation defined by the system Fixed Value: 电子健康档案共享文档 | |
encounter | 0..1 | Reference(随访服务结构定义) | Context of the Composition | |
title | 1..1 | string | 文档的标题 Required Pattern: II型糖尿病患者随访服务记录 | |
section | 7..* | (Slice Definition) | 文档的具体章节 Slice: Unordered, Open by value:code | |
section:PresentHistory | 1..1 | BackboneElement | Composition is broken into sections | |
title | 1..1 | string | 章节标题 Required Pattern: 现病史 | |
code | 1..1 | CodeableConcept | 章节的编码表示 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: History of Present illness | |
text | 0..1 | Narrative | 以文本形式描述现病史,如果当前未得病,可以写无现病史 | |
entry | 0..* | Reference(糖尿病症状结构定义) | 指向本地化定义的糖尿病症状资源 | |
section:SocialHistory | 1..1 | BackboneElement | Composition is broken into sections | |
title | 1..1 | string | 章节标题 Required Pattern: 社会环境史 | |
code | 1..1 | CodeableConcept | 章节的编码表示 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://loinc.org | |