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-realmHeader |
| Version: | 0.8.0.2022705 |
| Name: | RealmHeader |
| Title: | 通用文档本地化定义 |
| Status: | Active as of 2022-07-05T13:46:42+08:00 |
| Definition: | 通用文档本地化定义。 |
| Publisher: | CHIMA&HL7中国委员会 |
| Source Resource: | XML / JSON / Turtle |
通用文档本地化定义的正式唯一标识为:
http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-realmHeader
通用文档本地化定义是在FHIR标准的Clinical Document基础上进行更加详细的规则约束，下表展示了通用文档本地化定义的结构表示。
这种结构源自 Clinical Document
Summary
Mandatory: 8 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
这种结构源自 Clinical Document
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition | 0..* | Clinical Document | A set of resources composed into a single coherent clinical statement with clinical attestation | |
  id | Σ | 0..1 | string | Logical id of this artifact |
 meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
 extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
 composition-clinicaldocument-versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
| ext-composition-dataEnterer | 0..1 | Reference(Practitioner | PractitionerRole) | 文档的数据录入者 URL: http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/ext-composition-dataEnterer | |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 1..1 | Identifier | 文档的业务标识符 |
| status | ?!Σ | 1..1 | code | 文档的状态 Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type | Σ | 1..1 | CodeableConcept | 文档类型，由具体的文档定义指定其类型 Binding: 健康档案共享文档类型代码表 (required) |
| category | Σ | 1..1 | CodeableConcept | 文档的分类：EMR|EHR|PHR Binding: 共享文档类别代码表 (required) |
 subject | Σ | 1..1 | Reference(患者信息结构定义) | 指向诊疗活动中的患者 |
| encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition |
| date | Σ | 1..1 | dateTime | 文档的生成时间 |
| author | Σ | 1..1 | Reference(卫生服务人员信息结构定义) | 文档的作者 |
| title | Σ | 1..1 | string | 文档的标题 |
| confidentiality | Σ | 1..1 | code | 文档的保密级别 Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. |
 attester | 0..* | BackboneElement | 文档的责任人 | |
 id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |
| time | 0..1 | dateTime | When the composition was attested | |
 party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |
| custodian | Σ | 1..1 | Reference(医疗机构结构定义) | 文档所属管理机构 |
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |
  target[x] | 1..1 | Target of the relationship | ||
 targetIdentifier | Identifier | |||
| targetReference | Reference(Composition) | |||
| event | Σ | 0..* | BackboneElement | 文档记录的事件列表 |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. |
| period | Σ | 0..1 | Period | The period covered by the documentation |
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented |
| section | I | 1..* | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 1..1 | string | 章节标题 | |
| code | 1..1 | CodeableConcept | 章节的编码表示 Binding: 共享文档章节代码表 (required) | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | 文本描述 |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | I | 0..* | Reference(Resource) | 章节所包含的条目，指向一个资源 |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
 section | I | 0..* | See section (Composition) | Nested Section |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Clinical Document | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| Documentation for this format | ||||
这种结构源自 Clinical Document
Summary
Mandatory: 8 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
差异视图
这种结构源自 Clinical Document
快照视图
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Clinical Document | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| id | Σ | 0..1 | string | Logical id of this artifact |
| meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| composition-clinicaldocument-versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
| ext-composition-dataEnterer | 0..1 | Reference(Practitioner | PractitionerRole) | 文档的数据录入者 URL: http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/ext-composition-dataEnterer | |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 1..1 | Identifier | 文档的业务标识符 |
| status | ?!Σ | 1..1 | code | 文档的状态 Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type | Σ | 1..1 | CodeableConcept | 文档类型，由具体的文档定义指定其类型 Binding: 健康档案共享文档类型代码表 (required) |
| category | Σ | 1..1 | CodeableConcept | 文档的分类：EMR|EHR|PHR Binding: 共享文档类别代码表 (required) |
| subject | Σ | 1..1 | Reference(患者信息结构定义) | 指向诊疗活动中的患者 |
| encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition |
| date | Σ | 1..1 | dateTime | 文档的生成时间 |
| author | Σ | 1..1 | Reference(卫生服务人员信息结构定义) | 文档的作者 |
| title | Σ | 1..1 | string | 文档的标题 |
| confidentiality | Σ | 1..1 | code | 文档的保密级别 Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. |
| attester | 0..* | BackboneElement | 文档的责任人 | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |
| time | 0..1 | dateTime | When the composition was attested | |
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |
| custodian | Σ | 1..1 | Reference(医疗机构结构定义) | 文档所属管理机构 |
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |
| target[x] | 1..1 | Target of the relationship | ||
| targetIdentifier | Identifier | |||
| targetReference | Reference(Composition) | |||
| event | Σ | 0..* | BackboneElement | 文档记录的事件列表 |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. |
| period | Σ | 0..1 | Period | The period covered by the documentation |
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented |
| section | I | 1..* | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 1..1 | string | 章节标题 | |
| code | 1..1 | CodeableConcept | 章节的编码表示 Binding: 共享文档章节代码表 (required) | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | 文本描述 |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | I | 0..* | Reference(Resource) | 章节所包含的条目，指向一个资源 |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| Documentation for this format | ||||
本定义的其它表示法: Schematron
| Path | Conformance | ValueSet |
| Composition.language | preferred | CommonLanguages Max Binding: AllLanguages |
| Composition.status | required | CompositionStatus |
| Composition.type | required | VSEHRDocumentType |
| Composition.category | required | VSDocumentCategory |
| Composition.confidentiality | required | v3.ConfidentialityClassification |
| Composition.attester.mode | required | CompositionAttestationMode |
| Composition.relatesTo.code | required | DocumentRelationshipType |
| Composition.event.code | example | ActCode |
| Composition.section.code | required | DocSectionCodes |
| Composition.section.mode | required | ListMode |
| Composition.section.orderedBy | preferred | ListOrderCodes |
| Composition.section.emptyReason | preferred | ListEmptyReasons |
| Id | Path | Details | Requirements |
| dom-2 | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | Composition | 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 | Composition | 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 | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | Composition.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.extension:versionNumber | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.extension:versionNumber | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.extension:DataEnterer | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.extension:DataEnterer | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.status | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.category | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.subject | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.encounter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.date | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.confidentiality | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.attester.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.attester.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.attester.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.attester.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester.time | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester.party | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.custodian | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.relatesTo | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.relatesTo.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.relatesTo.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.relatesTo.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.relatesTo.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.relatesTo.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.relatesTo.target[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.event | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.event.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.event.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.event.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.event.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.event.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.event.period | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.event.detail | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |