基于FHIR标准的健康档案共享文档实施指南-检查结果结构定义

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: 检查结果结构定义

Defining URL:

http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-rad-result

Version:

0.8.0.2022705

Name:

RadResult

Title:

检查结果结构定义

Status:

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

Definition:

检查结果资源本地化定义。

Publisher:

CHIMA&HL7中国委员会

Source Resource:

XML / JSON / Turtle

检查结果结构定义的正式唯一标识为:

http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-rad-result

简介

检查结果使用Observation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检查结果的最低要求。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

检查结果结构定义是在FHIR标准的Observation基础上进行更加详细的规则约束，下表展示了检查结果结构定义的结构表示。

关于定义、差异、快照以及如何解读这些表示法。

文本摘要
差异表
快照表
快照表(Must Support)
All

这种结构源自 Observation

Summary

这种结构源自 Observation

Name	Flags	Card.	Type	Description & Constraints
Observation		0..*	Observation	Measurements and simple assertions
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Observation	I	0..*	Observation	Measurements and simple assertions
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	Business Identifier for observation
basedOn	Σ	0..*	Reference(CarePlan \| DeviceRequest \| ImmunizationRecommendation \| MedicationRequest \| NutritionOrder \| ServiceRequest)	Fulfills plan, proposal or order
partOf	Σ	0..*	Reference(MedicationAdministration \| MedicationDispense \| MedicationStatement \| Procedure \| Immunization \| ImagingStudy)	Part of referenced event
status	?!Σ	1..1	code	registered \| preliminary \| final \| amended + Binding: ObservationStatus (required): Codes providing the status of an observation.
category		0..*	CodeableConcept	Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
code	Σ	1..1	CodeableConcept	Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations.
subject	Σ	0..1	Reference(Patient \| Group \| Device \| Location)	Who and/or what the observation is about
focus	Σ	0..*	Reference(Resource)	What the observation is about, when it is not about the subject of record
encounter	Σ	0..1	Reference(Encounter)	Healthcare event during which this observation is made
effective[x]	Σ	0..1		Clinically relevant time/time-period for observation
effectiveDateTime			dateTime
effectivePeriod			Period
effectiveTiming			Timing
effectiveInstant			instant
issued	Σ	0..1	instant	Date/Time this version was made available
performer	Σ	0..*	Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam \| Patient \| RelatedPerson)	Who is responsible for the observation
value[x]	ΣI	0..1		Actual result
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	I	0..1	CodeableConcept	Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note		0..*	Annotation	Comments about the observation
bodySite		0..1	CodeableConcept	Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
method		0..1	CodeableConcept	How it was done Binding: ObservationMethods (example): Methods for simple observations.
specimen		0..1	Reference(Specimen)	Specimen used for this observation
device		0..1	Reference(Device \| DeviceMetric)	(Measurement) Device
referenceRange	I	0..*	BackboneElement	Provides guide for interpretation obs-3: Must have at least a low or a high or text
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
low	I	0..1	SimpleQuantity	Low Range, if relevant
high	I	0..1	SimpleQuantity	High Range, if relevant
type		0..1	CodeableConcept	Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
appliesTo		0..*	CodeableConcept	Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
age		0..1	Range	Applicable age range, if relevant
text		0..1	string	Text based reference range in an observation
hasMember	Σ	0..*	Reference(Observation \| QuestionnaireResponse \| MolecularSequence)	Related resource that belongs to the Observation group
derivedFrom	Σ	0..*	Reference(DocumentReference \| ImagingStudy \| Media \| QuestionnaireResponse \| Observation \| MolecularSequence)	Related measurements the observation is made from
component	Σ	0..*	BackboneElement	Component results
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	1..1	CodeableConcept	Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations.
value[x]	Σ	0..1		Actual component result
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	I	0..1	CodeableConcept	Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
referenceRange		0..*	See referenceRange (Observation)	Provides guide for interpretation of component result
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Observation	I	0..*	Observation	Measurements and simple assertions
Documentation for this format

这种结构源自 Observation

Summary

差异视图

这种结构源自 Observation

Name	Flags	Card.	Type	Description & Constraints
Observation		0..*	Observation	Measurements and simple assertions
Documentation for this format

快照视图

Name	Flags	Card.	Type	Description & Constraints
Observation	I	0..*	Observation	Measurements and simple assertions
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	Business Identifier for observation
basedOn	Σ	0..*	Reference(CarePlan \| DeviceRequest \| ImmunizationRecommendation \| MedicationRequest \| NutritionOrder \| ServiceRequest)	Fulfills plan, proposal or order
partOf	Σ	0..*	Reference(MedicationAdministration \| MedicationDispense \| MedicationStatement \| Procedure \| Immunization \| ImagingStudy)	Part of referenced event
status	?!Σ	1..1	code	registered \| preliminary \| final \| amended + Binding: ObservationStatus (required): Codes providing the status of an observation.
category		0..*	CodeableConcept	Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
code	Σ	1..1	CodeableConcept	Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations.
subject	Σ	0..1	Reference(Patient \| Group \| Device \| Location)	Who and/or what the observation is about
focus	Σ	0..*	Reference(Resource)	What the observation is about, when it is not about the subject of record
encounter	Σ	0..1	Reference(Encounter)	Healthcare event during which this observation is made
effective[x]	Σ	0..1		Clinically relevant time/time-period for observation
effectiveDateTime			dateTime
effectivePeriod			Period
effectiveTiming			Timing
effectiveInstant			instant
issued	Σ	0..1	instant	Date/Time this version was made available
performer	Σ	0..*	Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam \| Patient \| RelatedPerson)	Who is responsible for the observation
value[x]	ΣI	0..1		Actual result
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	I	0..1	CodeableConcept	Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note		0..*	Annotation	Comments about the observation
bodySite		0..1	CodeableConcept	Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
method		0..1	CodeableConcept	How it was done Binding: ObservationMethods (example): Methods for simple observations.
specimen		0..1	Reference(Specimen)	Specimen used for this observation
device		0..1	Reference(Device \| DeviceMetric)	(Measurement) Device
referenceRange	I	0..*	BackboneElement	Provides guide for interpretation obs-3: Must have at least a low or a high or text
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
low	I	0..1	SimpleQuantity	Low Range, if relevant
high	I	0..1	SimpleQuantity	High Range, if relevant
type		0..1	CodeableConcept	Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
appliesTo		0..*	CodeableConcept	Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
age		0..1	Range	Applicable age range, if relevant
text		0..1	string	Text based reference range in an observation
hasMember	Σ	0..*	Reference(Observation \| QuestionnaireResponse \| MolecularSequence)	Related resource that belongs to the Observation group
derivedFrom	Σ	0..*	Reference(DocumentReference \| ImagingStudy \| Media \| QuestionnaireResponse \| Observation \| MolecularSequence)	Related measurements the observation is made from
component	Σ	0..*	BackboneElement	Component results
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	1..1	CodeableConcept	Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations.
value[x]	Σ	0..1		Actual component result
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	I	0..1	CodeableConcept	Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
referenceRange		0..*	See referenceRange (Observation)	Provides guide for interpretation of component result
Documentation for this format

本定义的其它表示法: Schematron

Terminology Bindings

Path	Conformance	ValueSet
Observation.language	preferred	CommonLanguages Max Binding: AllLanguages
Observation.status	required	ObservationStatus
Observation.category	preferred	ObservationCategoryCodes
Observation.code	example	LOINCCodes
Observation.dataAbsentReason	extensible	DataAbsentReason
Observation.interpretation	extensible	ObservationInterpretationCodes
Observation.bodySite	example	SNOMEDCTBodyStructures
Observation.method	example	ObservationMethods
Observation.referenceRange.type	preferred	ObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesTo	example	ObservationReferenceRangeAppliesToCodes
Observation.component.code	example	LOINCCodes
Observation.component.dataAbsentReason	extensible	DataAbsentReason
Observation.component.interpretation	extensible	ObservationInterpretationCodes

Constraints

Id	Path	Details	Requirements
dom-2	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	Observation	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	Observation	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	Observation	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	Observation	A resource should have narrative for robust management : text.`div`.exists()
obs-6	Observation	dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty()
obs-7	Observation	If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
ele-1	Observation.meta	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.implicitRules	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.language	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.text	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Observation.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Observation.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Observation.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Observation.identifier	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.basedOn	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.partOf	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.status	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.category	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.code	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.subject	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.focus	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.encounter	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.effective[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.issued	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.performer	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.value[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.dataAbsentReason	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.interpretation	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.note	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.bodySite	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.method	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.specimen	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.device	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.referenceRange	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
obs-3	Observation.referenceRange	Must have at least a low or a high or text : low.exists() or high.exists() or text.exists()
ele-1	Observation.referenceRange.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Observation.referenceRange.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Observation.referenceRange.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Observation.referenceRange.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Observation.referenceRange.low	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.referenceRange.high	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.referenceRange.type	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.referenceRange.appliesTo	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.referenceRange.age	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.referenceRange.text	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.hasMember	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.derivedFrom	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.component	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.component.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Observation.component.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Observation.component.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Observation.component.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Observation.component.code	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.component.value[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.component.dataAbsentReason	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.component.interpretation	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.component.referenceRange	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())