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。

Resource Profile: 脑卒中患者随访服务共享文档本地化定义

Defining URL:http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-document-hsdb04-06
Version:0.8.0.2022705
Name:DocumentHSDB0406
Title:脑卒中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:

脑卒中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

脑卒中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-hsdb04-06

定义内容的视图

脑卒中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，下表展示了脑卒中患者随访服务共享文档本地化定义的结构表示。

关于定义、差异、快照以及如何解读这些表示法。

这种结构源自 RealmHeader

Summary

Mandatory: 10 elements (1 nested mandatory element)
Must-Support: 3 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Composition.section is sliced based on the value of value:code

这种结构源自 RealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*RealmHeaderA set of resources composed into a single coherent clinical statement with clinical attestation
... type 1..1CodeableConcept文档类型，由具体的文档定义指定其类型
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org.cn/fhir/sd/ehr/CodeSystem/ehr-document-type
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: HSDB04.06
..... display1..1stringRepresentation defined by the system
Fixed Value: 脑卒中患者随访服务
... category 1..1CodeableConcept文档的分类：EMR|EHR|PHR
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org.cn/fhir/sd/ehr/CodeSystem/document-category
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: EHR
..... display1..1stringRepresentation defined by the system
Fixed Value: 电子健康档案共享文档
... encounter 0..1Reference(随访服务结构定义)Context of the Composition
... section 7..*(Slice Definition)文档的具体章节
Slice: Unordered, Open by value:code
.... section:PresentHistory 1..1BackboneElementComposition is broken into sections
..... title 1..1string章节标题
Required Pattern: 现病史
..... code 1..1CodeableConcept章节的编码表示
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10164-2
....... display1..1stringRepresentation defined by the system
Fixed Value: History of Present illness
..... text 0..1Narrative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(脑卒中症状结构定义)指向本地化定义的脑卒中症状资源
.... section:SocialHistory 1..1BackboneElementComposition is broken into sections
..... title 1..1string章节标题
Required Pattern: 社会环境史
..... code 1..1CodeableConcept章节的编码表示
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 29762-2
....... display1..1stringRepresentation defined by the system
Fixed Value: Social history
..... entry 0..*Reference(日饮酒量结构定义 | 日吸烟量结构定义 | 运动情况结构定义)指向本地化定义的生活方式资源
.... section:VitalSigns 1..1BackboneElement记录随访时的患者的多种生命体征信息。
..... title 1..1string章节标题
Required Pattern: 生命体征
..... code 1..1CodeableConcept章节的编码表示
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 8716-3
....... display1..1stringRepresentation defined by the system
Fixed Value: Vital signs
..... entry 1..*Reference(身高结构定义 | 体重结构定义 | 体质指数结构定义 | 血压结构定义 | 心率结构定义 | 腰围结构定义)指向本地化定义的生命体征资源
.... section:LabResult S0..1BackboneElement记录随访时为患者做的检验项目结果数据。
..... title 1..1string章节标题
Required Pattern: 检验结果
..... code 1..1CodeableConcept章节的编码表示
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 30954-2
....... display1..1stringRepresentation defined by the system
Fixed Value: Laboratory data
..... entry 0..*Reference(检验结果结构定义)指向本地化定义的检验结果资源
.... section:CurrentMedUse 1..1BackboneElement记录随访周期内患者的用药情况。
..... title 1..1string章节标题
Required Pattern: 当前用药
..... code 1..1CodeableConcept章节的编码表示
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 19009-0
....... display1..1stringRepresentation 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 S0..1BackboneElement记录随访周期内患者的用药不良反应。
..... title 1..1string章节标题
Required Pattern: 过敏和不良反应
..... code 1..1CodeableConcept章节的编码表示
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 48765-2
....... display1..1stringRepresentation 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..1BackboneElement记录随访时为患者做的评估和目标规划。
..... title 1..1string章节标题
Required Pattern: 评估与计划
..... code 1..1CodeableConcept章节的编码表示
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 51847-2
....... display1..1stringRepresentation defined by the system
Fixed Value: Evaluation and plan
..... entry 0..*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..1BackboneElement记录随访时为患者做的目标和治疗计划。
..... title 1..1string章节标题
Required Pattern: 治疗计划
..... code 1..1CodeableConcept章节的编码表示
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 18776-5
....... display1..1stringRepresentation 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)指向本地化定义的生活方式目标资源
.... section:Referral S0..1BackboneElement记录随访时为患者提出的转诊申请。
..... title 1..1string章节标题
Required Pattern: 转诊建议
..... code 1..1CodeableConcept章节的编码表示
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 42349-1
....... display1..1stringRepresentation defined by the system
Fixed Value: Reason for referral
..... entry 1..1Reference(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..1BackboneElement记录下一次的随访计划。
..... title 1..1string章节标题
Required Pattern: 随访计划
..... code 1..1CodeableConcept章节的编码表示
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 21979-0
....... display1..1stringRepresentation defined by the system
Fixed Value: Planned/next follow-up
..... entry 1..1Reference(随访服务结构定义)指向本地化定义的随访活动资源

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*RealmHeaderA set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... composition-clinicaldocument-versionNumber 0..*stringVersion-specific identifier for composition
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
... ext-composition-dataEnterer 0..1Reference(Practitioner | PractitionerRole)文档的数据录入者
URL: http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/ext-composition-dataEnterer
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ1..1Identifier文档的业务标识符
... status ?!Σ1..1code文档的状态
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... type Σ1..1CodeableConcept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
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org.cn/fhir/sd/ehr/CodeSystem/ehr-document-type
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: HSDB04.06
..... display1..1stringRepresentation defined by the system
Fixed Value: 脑卒中患者随访服务
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... category Σ1..1CodeableConcept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
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org.cn/fhir/sd/ehr/CodeSystem/document-category
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: EHR
..... display1..1stringRepresentation defined by the system
Fixed Value: 电子健康档案共享文档
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... subject Σ1..1Reference(患者信息结构定义)指向诊疗活动中的患者
... encounter Σ0..1Reference(随访服务结构定义)Context of the Composition
... date Σ1..1dateTime文档的生成时间
... author Σ1..1Reference(卫生服务人员信息结构定义)文档的作者
... title Σ1..1string文档的标题
Required Pattern: 脑卒中患者随访服务记录
... confidentiality Σ1..1code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..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode 1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

.... time 0..1dateTimeWhen the composition was attested
.... party 0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Who attested the composition
... custodian Σ1..1Reference(医疗机构结构定义)文档所属管理机构
... relatesTo 0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target[x] 1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event Σ0..*BackboneElement文档记录的事件列表
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ0..*CodeableConceptCode(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 Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... section I7..*(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..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1string章节标题
..... code 1..1CodeableConcept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..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1Narrative文本描述
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry I0..*Reference(Resource)章节所包含的条目，指向一个资源
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section
.... section:PresentHistory I1..1BackboneElementComposition is broken into sections
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1string章节标题
Required Pattern: 现病史
..... code 1..1CodeableConcept章节的编码表示
Binding: 共享文档章节代码表 (required)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10164-2
....... display1..1stringRepresentation defined by the system
Fixed Value: History of Present illness
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1Narrative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..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry I0..*Reference(脑卒中症状结构定义)指向本地化定义的脑卒中症状资源
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section
.... section:SocialHistory I1..1BackboneElementComposition is broken into sections
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1string章节标题
Required Pattern: 社会环境史
..... code 1..1CodeableConcept章节的编码表示
Binding: 共享文档章节代码表 (required)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 29762-2
....... display1..1stringRepresentation defined by the system
Fixed Value: Social history
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1Narrative文本描述
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry I0..*Reference(日饮酒量结构定义 | 日吸烟量结构定义 | 运动情况结构定义)指向本地化定义的生活方式资源
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section
.... section:VitalSigns I1..1BackboneElement记录随访时的患者的多种生命体征信息。
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1string章节标题
Required Pattern: 生命体征
..... code 1..1CodeableConcept章节的编码表示
Binding: 共享文档章节代码表 (required)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 8716-3
....... display1..1stringRepresentation defined by the system
Fixed Value: Vital signs
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1Narrative文本描述
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry I1..*Reference(身高结构定义 | 体重结构定义 | 体质指数结构定义 | 血压结构定义 | 心率结构定义 | 腰围结构定义)指向本地化定义的生命体征资源
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section
.... section:LabResult SI0..1BackboneElement记录随访时为患者做的检验项目结果数据。
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1string章节标题
Required Pattern: 检验结果
..... code 1..1CodeableConcept章节的编码表示
Binding: 共享文档章节代码表 (required)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 30954-2
....... display1..1stringRepresentation defined by the system
Fixed Value: Laboratory data
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1Narrative文本描述
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry I0..*Reference(检验结果结构定义)指向本地化定义的检验结果资源
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section
.... section:CurrentMedUse I1..1BackboneElement记录随访周期内患者的用药情况。
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1string章节标题
Required Pattern: 当前用药
..... code 1..1CodeableConcept章节的编码表示
Binding: 共享文档章节代码表 (required)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 19009-0
....... display1..1stringRepresentation defined by the system
Fixed Value: Medication current
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1Narrative文本描述
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry I0..*Reference(用药声明结构定义)指向本地化定义的当前用药资源
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section
.... section:ADR SI0..1BackboneElement记录随访周期内患者的用药不良反应。
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1string章节标题
Required Pattern: 过敏和不良反应
..... code 1..1CodeableConcept章节的编码表示
Binding: 共享文档章节代码表 (required)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 48765-2
....... display1..1stringRepresentation defined by the system
Fixed Value: Allergies and adverse reactions
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1Narrative文本描述
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry I0..*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 I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section
.... section:Assessment I1..1BackboneElement记录随访时为患者做的评估和目标规划。
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1string章节标题
Required Pattern: 评估与计划
..... code 1..1CodeableConcept章节的编码表示
Binding: 共享文档章节代码表 (required)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 51847-2
....... display1..1stringRepresentation defined by the system
Fixed Value: Evaluation and plan
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1Narrative文本描述
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry I0..*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 I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section
.... section:TreatmentPlan I1..1BackboneElement记录随访时为患者做的目标和治疗计划。
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1string章节标题
Required Pattern: 治疗计划
..... code 1..1CodeableConcept章节的编码表示
Binding: 共享文档章节代码表 (required)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 18776-5
....... display1..1stringRepresentation defined by the system
Fixed Value: Plan of care
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1Narrative文本描述
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry I1..*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)指向本地化定义的生活方式目标资源
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section
.... section:Referral SI0..1BackboneElement记录随访时为患者提出的转诊申请。
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1string章节标题
Required Pattern: 转诊建议
..... code 1..1CodeableConcept章节的编码表示
Binding: 共享文档章节代码表 (required)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 42349-1
....... display1..1stringRepresentation defined by the system
Fixed Value: Reason for referral
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1Narrative文本描述
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry I1..1Reference(转诊申请结构定义)指向本地化定义的转诊申请资源
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section
.... section:Plan I1..1BackboneElement记录下一次的随访计划。
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 1..1string章节标题
Required Pattern: 随访计划
..... code 1..1CodeableConcept章节的编码表示
Binding: 共享文档章节代码表 (required)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 21979-0
....... display1..1stringRepresentation defined by the system
Fixed Value: Planned/next follow-up
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1Narrative文本描述
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry I1..1Reference(随访服务结构定义)指向本地化定义的随访活动资源
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*RealmHeaderA set of resources composed into a single coherent clinical statement with clinical attestation
... section:LabResult I0..1BackboneElement记录随访时为患者做的检验项目结果数据。
... section:ADR I0..1BackboneElement记录随访周期内患者的用药不良反应。
... section:Referral I0..1BackboneElement记录随访时为患者提出的转诊申请。

doco Documentation for this format

这种结构源自 RealmHeader

Summary

Mandatory: 10 elements (1 nested mandatory element)
Must-Support: 3 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Composition.section is sliced based on the value of value:code

差异视图

这种结构源自 RealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*RealmHeaderA set of resources composed into a single coherent clinical statement with clinical attestation
... type 1..1CodeableConcept文档类型，由具体的文档定义指定其类型
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org.cn/fhir/sd/ehr/CodeSystem/ehr-document-type
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: HSDB04.06
..... display1..1stringRepresentation defined by the system
Fixed Value: 脑卒中患者随访服务
... category 1..1CodeableConcept文档的分类：EMR|EHR|PHR
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org.cn/fhir/sd/ehr/CodeSystem/document-category
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: EHR
..... display1..1stringRepresentation defined by the system
Fixed Value: 电子健康档案共享文档
... encounter 0..1Reference(随访服务结构定义)Context of the Composition
... section 7..*(Slice Definition)文档的具体章节
Slice: Unordered, Open by value:code
.... section:PresentHistory 1..1BackboneElementComposition is broken into sections
..... title 1..1string章节标题
Required Pattern: 现病史
..... code 1..1CodeableConcept章节的编码表示
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10164-2
....... display1..1stringRepresentation defined by the system
Fixed Value: History of Present illness
..... text 0..1Narrative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(脑卒中症状结构定义)指向本地化定义的脑卒中症状资源
.... section:SocialHistory 1..1BackboneElementComposition is broken into sections
..... title 1..1string章节标题
Required Pattern: 社会环境史
..... code 1..1CodeableConcept章节的编码表示
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: htt