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-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
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。
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。
这种结构源自 MedicationStatement
Summary
Mandatory: 6 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
这种结构源自 MedicationStatement
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 | |
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:
Slices
This structure defines the following Slices:
差异视图
这种结构源自 MedicationStatement
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 | |
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
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 |
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()) |