基于FHIR标准的健康档案共享文档实施指南-用药声明结构定义

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: 用药声明结构定义

Defining URL:

http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-medical-use

Version:

0.8.0.2022705

Name:

MedicationUse

Title:

用药声明结构定义

Status:

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

Definition:

用药声明资源本地化定义。

Publisher:

CHIMA&HL7中国委员会

Source Resource:

XML / JSON / Turtle

用药声明结构定义的正式唯一标识为:

http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-medical-use

简介

用药声明使用MedicationStatement资源进行表示。该资源的本地化结构定义声明了对适用于健康医疗信息平台中用药声明的最低要求。它确定在使用此资源时应包含哪些核心元素、扩展和术语。

快速实施指导

定义内容的视图

用药声明结构定义是在FHIR标准的MedicationStatement基础上进行更加详细的规则约束，下表展示了用药声明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。

这种结构源自 MedicationStatement

Summary

Mandatory: 6 elements

Structures

This structure refers to these other structures:

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

Slices

This structure defines the following Slices:

The element MedicationStatement.medication[x] is sliced based on the value of type:$this

这种结构源自 MedicationStatement

Name	Card.	Type	Description & Constraints
MedicationStatement	0..*	MedicationStatement	用于记录在过去一段时间内的用药情况说明
status	1..1	code	用药声明的状态
medication[x]	1..1	(Slice Definition)	What medication was taken Slice: Unordered, Open by type:$this
medicationCodeableConcept	1..1	CodeableConcept	What medication was taken
subject	1..1	Reference(患者信息结构定义)	患者
context	1..1	Reference(Encounter \| EpisodeOfCare)	用药关联的诊疗活动。
dosage	1..1	Dosage	用药剂量说明
timing	1..1	Timing	用药频率
route	1..1	CodeableConcept	用药途径
method	0..1	CodeableConcept	用药方法
doseAndRate	1..1	Element	剂量和速率
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
MedicationStatement		0..*	MedicationStatement	用于记录在过去一段时间内的用药情况说明
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 identifier
basedOn	Σ	0..*	Reference(MedicationRequest \| CarePlan \| ServiceRequest)	Fulfils plan, proposal or order
partOf	Σ	0..*	Reference(MedicationAdministration \| MedicationDispense \| MedicationStatement \| Procedure \| Observation)	Part of referenced event
status	?!Σ	1..1	code	用药声明的状态 Binding: Medication Status Codes (required): A coded concept indicating the current status of a MedicationStatement.
statusReason		0..*	CodeableConcept	Reason for current status Binding: SNOMEDCTDrugTherapyStatusCodes (example): A coded concept indicating the reason for the status of the statement.
category	Σ	0..1	CodeableConcept	Type of medication usage Binding: Medication usage category codes (preferred): A coded concept identifying where the medication included in the MedicationStatement is expected to be consumed or administered.
medication[x]	Σ	1..1	(Slice Definition)	What medication was taken Slice: Unordered, Closed by type:$this Binding: SNOMEDCTMedicationCodes (example): A coded concept identifying the substance or product being taken.
medication[x]:medicationCodeableConcept	Σ	1..1	CodeableConcept	What medication was taken Binding: SNOMEDCTMedicationCodes (example): A coded concept identifying the substance or product being taken.
subject	Σ	1..1	Reference(患者信息结构定义)	患者
context	Σ	1..1	Reference(Encounter \| EpisodeOfCare)	用药关联的诊疗活动。
effective[x]	Σ	0..1		The date/time or interval when the medication is/was/will be taken
effectiveDateTime			dateTime
effectivePeriod			Period
dateAsserted	Σ	0..1	dateTime	When the statement was asserted?
informationSource		0..1	Reference(Patient \| Practitioner \| PractitionerRole \| RelatedPerson \| Organization)	Person or organization that provided the information about the taking of this medication
derivedFrom		0..*	Reference(Resource)	Additional supporting information
reasonCode		0..*	CodeableConcept	Reason for why the medication is being/was taken Binding: Condition/Problem/DiagnosisCodes (example): A coded concept identifying why the medication is being taken.
reasonReference		0..*	Reference(Condition \| Observation \| DiagnosticReport)	Condition or observation that supports why the medication is being/was taken
note		0..*	Annotation	Further information about the statement
dosage		1..1	Dosage	用药剂量说明
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	Σ	0..1	integer	The order of the dosage instructions
text	Σ	0..1	string	Free text dosage instructions e.g. SIG
additionalInstruction	Σ	0..*	CodeableConcept	Supplemental instruction or warnings to the patient - e.g. "with meals", "may cause drowsiness" Binding: SNOMEDCTAdditionalDosageInstructions (example): A coded concept identifying additional instructions such as "take with water" or "avoid operating heavy machinery".
patientInstruction	Σ	0..1	string	Patient or consumer oriented instructions
timing	Σ	1..1	Timing	用药频率
asNeeded[x]	Σ	0..1		Take "as needed" (for x) Binding: SNOMEDCTMedicationAsNeededReasonCodes (example): A coded concept identifying the precondition that should be met or evaluated prior to consuming or administering a medication dose. For example "pain", "30 minutes prior to sexual intercourse", "on flare-up" etc.
asNeededBoolean			boolean
asNeededCodeableConcept			CodeableConcept
site	Σ	0..1	CodeableConcept	Body site to administer to Binding: SNOMEDCTAnatomicalStructureForAdministrationSiteCodes (example): A coded concept describing the site location the medicine enters into or onto the body.
route	Σ	1..1	CodeableConcept	用药途径 Binding: SNOMEDCTRouteCodes (example): A coded concept describing the route or physiological path of administration of a therapeutic agent into or onto the body of a subject.
method	Σ	0..1	CodeableConcept	用药方法 Binding: SNOMEDCTAdministrationMethodCodes (example): A coded concept describing the technique by which the medicine is administered.
doseAndRate	Σ	1..1	Element	剂量和速率
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
type	Σ	0..1	CodeableConcept	The kind of dose or rate specified Binding: DoseAndRateType (example): The kind of dose or rate specified.
dose[x]	Σ	0..1		Amount of medication per dose
doseRange			Range
doseQuantity			Quantity(SimpleQuantity)
rate[x]	Σ	0..1		Amount of medication per unit of time
rateRatio			Ratio
rateRange			Range
rateQuantity			Quantity(SimpleQuantity)
maxDosePerPeriod	Σ	0..1	Ratio	Upper limit on medication per unit of time
maxDosePerAdministration	Σ	0..1	SimpleQuantity	Upper limit on medication per administration
maxDosePerLifetime	Σ	0..1	SimpleQuantity	Upper limit on medication per lifetime of the patient
Documentation for this format

这种结构源自 MedicationStatement

Summary

Mandatory: 6 elements

Structures

This structure refers to these other structures:

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

Slices

This structure defines the following Slices:

The element MedicationStatement.medication[x] is sliced based on the value of type:$this

差异视图

这种结构源自 MedicationStatement

Name	Card.	Type	Description & Constraints
MedicationStatement	0..*	MedicationStatement	用于记录在过去一段时间内的用药情况说明
status	1..1	code	用药声明的状态
medication[x]	1..1	(Slice Definition)	What medication was taken Slice: Unordered, Open by type:$this
medicationCodeableConcept	1..1	CodeableConcept	What medication was taken
subject	1..1	Reference(患者信息结构定义)	患者
context	1..1	Reference(Encounter \| EpisodeOfCare)	用药关联的诊疗活动。
dosage	1..1	Dosage	用药剂量说明
timing	1..1	Timing	用药频率
route	1..1	CodeableConcept	用药途径
method	0..1	CodeableConcept	用药方法
doseAndRate	1..1	Element	剂量和速率
Documentation for this format

快照视图

Name	Flags	Card.	Type	Description & Constraints
MedicationStatement		0..*	MedicationStatement	用于记录在过去一段时间内的用药情况说明
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 identifier
basedOn	Σ	0..*	Reference(MedicationRequest \| CarePlan \| ServiceRequest)	Fulfils plan, proposal or order
partOf	Σ	0..*	Reference(MedicationAdministration \| MedicationDispense \| MedicationStatement \| Procedure \| Observation)	Part of referenced event
status	?!Σ	1..1	code	用药声明的状态 Binding: Medication Status Codes (required): A coded concept indicating the current status of a MedicationStatement.
statusReason		0..*	CodeableConcept	Reason for current status Binding: SNOMEDCTDrugTherapyStatusCodes (example): A coded concept indicating the reason for the status of the statement.
category	Σ	0..1	CodeableConcept	Type of medication usage Binding: Medication usage category codes (preferred): A coded concept identifying where the medication included in the MedicationStatement is expected to be consumed or administered.
medication[x]	Σ	1..1	(Slice Definition)	What medication was taken Slice: Unordered, Closed by type:$this Binding: SNOMEDCTMedicationCodes (example): A coded concept identifying the substance or product being taken.
medication[x]:medicationCodeableConcept	Σ	1..1	CodeableConcept	What medication was taken Binding: SNOMEDCTMedicationCodes (example): A coded concept identifying the substance or product being taken.
subject	Σ	1..1	Reference(患者信息结构定义)	患者
context	Σ	1..1	Reference(Encounter \| EpisodeOfCare)	用药关联的诊疗活动。
effective[x]	Σ	0..1		The date/time or interval when the medication is/was/will be taken
effectiveDateTime			dateTime
effectivePeriod			Period
dateAsserted	Σ	0..1	dateTime	When the statement was asserted?
informationSource		0..1	Reference(Patient \| Practitioner \| PractitionerRole \| RelatedPerson \| Organization)	Person or organization that provided the information about the taking of this medication
derivedFrom		0..*	Reference(Resource)	Additional supporting information
reasonCode		0..*	CodeableConcept	Reason for why the medication is being/was taken Binding: Condition/Problem/DiagnosisCodes (example): A coded concept identifying why the medication is being taken.
reasonReference		0..*	Reference(Condition \| Observation \| DiagnosticReport)	Condition or observation that supports why the medication is being/was taken
note		0..*	Annotation	Further information about the statement
dosage		1..1	Dosage	用药剂量说明
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	Σ	0..1	integer	The order of the dosage instructions
text	Σ	0..1	string	Free text dosage instructions e.g. SIG
additionalInstruction	Σ	0..*	CodeableConcept	Supplemental instruction or warnings to the patient - e.g. "with meals", "may cause drowsiness" Binding: SNOMEDCTAdditionalDosageInstructions (example): A coded concept identifying additional instructions such as "take with water" or "avoid operating heavy machinery".
patientInstruction	Σ	0..1	string	Patient or consumer oriented instructions
timing	Σ	1..1	Timing	用药频率
asNeeded[x]	Σ	0..1		Take "as needed" (for x) Binding: SNOMEDCTMedicationAsNeededReasonCodes (example): A coded concept identifying the precondition that should be met or evaluated prior to consuming or administering a medication dose. For example "pain", "30 minutes prior to sexual intercourse", "on flare-up" etc.
asNeededBoolean			boolean
asNeededCodeableConcept			CodeableConcept
site	Σ	0..1	CodeableConcept	Body site to administer to Binding: SNOMEDCTAnatomicalStructureForAdministrationSiteCodes (example): A coded concept describing the site location the medicine enters into or onto the body.
route	Σ	1..1	CodeableConcept	用药途径 Binding: SNOMEDCTRouteCodes (example): A coded concept describing the route or physiological path of administration of a therapeutic agent into or onto the body of a subject.
method	Σ	0..1	CodeableConcept	用药方法 Binding: SNOMEDCTAdministrationMethodCodes (example): A coded concept describing the technique by which the medicine is administered.
doseAndRate	Σ	1..1	Element	剂量和速率
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
type	Σ	0..1	CodeableConcept	The kind of dose or rate specified Binding: DoseAndRateType (example): The kind of dose or rate specified.
dose[x]	Σ	0..1		Amount of medication per dose
doseRange			Range
doseQuantity			Quantity(SimpleQuantity)
rate[x]	Σ	0..1		Amount of medication per unit of time
rateRatio			Ratio
rateRange			Range
rateQuantity			Quantity(SimpleQuantity)
maxDosePerPeriod	Σ	0..1	Ratio	Upper limit on medication per unit of time
maxDosePerAdministration	Σ	0..1	SimpleQuantity	Upper limit on medication per administration
maxDosePerLifetime	Σ	0..1	SimpleQuantity	Upper limit on medication per lifetime of the patient
Documentation for this format

本定义的其它表示法: Schematron

Terminology Bindings

Path	Conformance	ValueSet
MedicationStatement.language	preferred	CommonLanguages Max Binding: AllLanguages
MedicationStatement.status	required	Medication Status Codes
MedicationStatement.statusReason	example	SNOMEDCTDrugTherapyStatusCodes
MedicationStatement.category	preferred	Medication usage category codes
MedicationStatement.medication[x]	example	SNOMEDCTMedicationCodes
MedicationStatement.medication[x]:medicationCodeableConcept	example	SNOMEDCTMedicationCodes
MedicationStatement.reasonCode	example	Condition/Problem/DiagnosisCodes
MedicationStatement.dosage.additionalInstruction	example	SNOMEDCTAdditionalDosageInstructions
MedicationStatement.dosage.asNeeded[x]	example	SNOMEDCTMedicationAsNeededReasonCodes
MedicationStatement.dosage.site	example	SNOMEDCTAnatomicalStructureForAdministrationSiteCodes
MedicationStatement.dosage.route	example	SNOMEDCTRouteCodes
MedicationStatement.dosage.method	example	SNOMEDCTAdministrationMethodCodes
MedicationStatement.dosage.doseAndRate.type	example	DoseAndRateType

Constraints

Id	Path	Details	Requirements
dom-2	MedicationStatement	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	MedicationStatement	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	MedicationStatement	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	MedicationStatement	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	MedicationStatement	A resource should have narrative for robust management : text.`div`.exists()
ele-1	MedicationStatement.meta	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.implicitRules	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.language	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.text	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	MedicationStatement.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	MedicationStatement.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	MedicationStatement.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	MedicationStatement.identifier	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.basedOn	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.partOf	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.status	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.statusReason	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.category	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.medication[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.medication[x]:medicationCodeableConcept	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.subject	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.context	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.effective[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.dateAsserted	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.informationSource	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.derivedFrom	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.reasonCode	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.reasonReference	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.note	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.dosage	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.dosage.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	MedicationStatement.dosage.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	MedicationStatement.dosage.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	MedicationStatement.dosage.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	MedicationStatement.dosage.sequence	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.dosage.text	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.dosage.additionalInstruction	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.dosage.patientInstruction	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.dosage.timing	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.dosage.asNeeded[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.dosage.site	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.dosage.route	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.dosage.method	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.dosage.doseAndRate	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.dosage.doseAndRate.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	MedicationStatement.dosage.doseAndRate.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	MedicationStatement.dosage.doseAndRate.type	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.dosage.doseAndRate.dose[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.dosage.doseAndRate.rate[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.dosage.maxDosePerPeriod	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.dosage.maxDosePerAdministration	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	MedicationStatement.dosage.maxDosePerLifetime	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())